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Mini-form 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)

* Email

* Cell Phone

* 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.

Have there been any changes in your financial situation since last year? If you have experienced significant changes in income or expenses since last year, please use the full FA form.

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
	No

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

	Yes
	No

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

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*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

Comments

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

Total:

Mini-form FA 2021-2022

Account Details

Enter your name and e-mail address for your confirmation:

Payment Information

Credit Card

Checking Account

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