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FA 2021-2022

Congregation Beth Chaim

Confidential Application for Financial Assistance

Fiscal Year: July 1, 2021 to June 30, 2022

Please click each relevant section.

Family Information

* Family Name(s)

* Address

* City, State, Zip

* Home Phone

Preferred Method of Contact

* CERTIFICATION AND AUTHORIZATION

Adult 1 - Yes

Adult 2 - Yes

I/We declare that to the best of my/our knowledge, the information reported in this form is correct and complete. The Financial Assistance Committee of Congregation Beth Chaim has my/our permission to verify the information reported.

Adult 1

* Full Name

* Birthdate

* Email

* Cell Phone

Employment Information

* Occupation Title

* Employer Name

* City, State

Adult 2

Full Name

Birthdate

Cell Phone

Employment Information

Occupation Title

Employer Name

City, State

Child 1

Name

Age

School Grade

Attending Religious School?

Yes

B'nei Mitzvah Date (if known)

Confirmation Class?

Yes

Child 2

Name

Age

School Grade

Attending Religious School?

Yes

B'nei Mitzvah Date (if known)

Confirmation Class?

Yes

Child 3

Name

Age

School Grade

Attending Religious School?

Yes

B'nei Mitzvah Date (if known)

Confirmation Class

Yes

Other Dependants

* Any other dependents being supported by Congregant(s)

Yes

If Yes, please list names and relationship to Congregant(s)

Financial Information

Monthly Income (if applicable)

Wages / Salaries / etc.

Social Security

Interest / Diviidends

Other (please list)

* Total Income

Monthly Housing Expenses

Mortgage payment(s)

Home Equity Payment

R/E Taxes / Insurance, if not paid with mortgage

Condo Fees

Rent

* Total Housing Expenses

Additional Household Expenses

Auto Payment(s)

Credit Card Payments

Out-of-Pocket Medical

College or Private School Tuition

* Total Monthly Expenses

Monthly Discretionary Income

* Monthly Income less housing and additional expenses

Household Educational Expenses

Number of members of household who will be in college, graduate or professional school, or other post high school educational institution at least half-time during the school year 2021-2022

Child 1

Student Name

Institution Name

Total Annual Educational Expense

Total Annual Scholarships & Grants

Student’s Assets Not Included Above

Child 2

Student Name

Institution Name

Total Annual Educational Expense

Total Annual Scholarships & Grants

Student’s Assets Not Included Above

Child 3

Student Name

Institution Name

Total Annual Educational Expense

Total Annual Scholarships & Grants

Student’s Assets Not Included Above

Reason for applying for financial assistance

Please describe the special circumstances or problems that will help the Financial Assistance Committee in evaluating your need for financial assistance such as changes in employment, uninsured medical expenses:

Form Completion Information

* Monthly amount you believe you can afford to pay Congregation Beth Chaim for fiscal year 2022 (July 1, 2021 -- June 30, 2022)

Please make a good-faith payment to your ability while determination is made by the FA committee. Thank you.

Optional:

Would you like to have a member of the Beth Chaim clergy consulted on this application?

Yes

Would you like to have Beth Chaim's Director of Lifelong Education consulted on this application?

Yes

The Financial Secretary will honor these requests throughout this application process.

Account Details

E-mail

Enter your name and e-mail address for your confirmation

First Name

Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Checking Account

Name on the Account

Bank Name

Routing Number

Is usually located between the symbols on your check.

Account Number

Typically comes before the symbols. Its exact location and number of digits varies from bank to bank.

Confirm Account Number

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

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