Dues Reduction Form

CONFIDENTIAL APPLICATION FOR REDUCTION

Return Form by July 1

POLICY: No one is to be denied access to synagogue membership because of a genuine inability to pay.

CONFIDENTIALITY: All dues Reduction Committee ("DRC") proceedings are strictly confidential.

If you wish to request a reduction in your dues, building fund, or religious school, you must fully complete this form for consideration. A new form must be completed each fiscal year you wish to have a reduction.

Membership Category (please select one)

Family (two or more)Single

Adult (partner one, P1)

Adult (partner two, P2)

* Name

Name

* Birth Date

Birth Date

* Home Address

* City

* State

* Zip Code

* Home Phone

* Work/Cell Phone

Work/Cell Phone

* Best time and phone to call

Best time and phone to call

* Personal E-mail address

Personal E-mail address

* Employment Status (please select one)

EmployedUnemployedRetired

Employment Status (please select one)

EmployedUnemployedRetired

* Current Employer

Current Employer

* Position/Title

Position/Title

Length of Employment

Work Email Address

Number of Persons Being Supported (including self, children, parents, and others):

Children living at home:

Name

Age

Will Child attend Religious School next year:

Name

Age

Will Child attend Religious School next year:

Name

Age

Will Child attend Religious School next year:

Name

Age

Will Child attend Religious School next year:

Other Dependents

School(s) children currently attend

* Total household gross income for last calendar year

* Total expected household income for current calendar year

Any other extenuating circumstances you would like the DRC to consider (Feel free to use a separate piece of paper if further explanation is required.)

I requested a dues reduction last fiscal year

List reduced obligation amounts

for last fiscal year

List amount paid

last year

* Dues (fill in $ amount)

Dues (fill in $ amount)

Religious School (fill in $ amount)

Statement of Ability to Pay for 23-24 Fiscal Year

Understanding that all members of Rodeph Sholom are expected to pay dues to the extent and in an amount that they are financially able to do so, I/we state that I/we can reasonably pay the following by May 31, 2024.

* Total Dues Able to Pay

Payments toward obligations may be made before a reduction is received/approved.

The Dues Reduction Committee encourages applicants to use automatic credit card payment processing, a service that Rodeph Sholom provides without charge.

I/we hereby affirm that all of the information provided in this Confidential Financial Application for Reduction is true and accurate to the best of my/our knowledge. I/we understand and agree that verification of the above statements will be provided to the Dues Reduction Committee for review upon request.

* Print Name

Print Name

If you have questions about this form or the Dues Reduction process, please contact the Executive Director at 813-837-1911 or email Director@RSholom.org.

Sat, April 20 2024 12 Nisan 5784