Temple Beth Sholom

10700 Havenwood Lane, Las Vegas, Nevada 89135, (702) 804-1333

MEMBERSHIP AND/OR RELIGIOUS SCHOOL FEE ADJUSTMENT APPLICATION

SUBMIT BY JUNE 1 FOR 2009 – 2010 FISCAL YEAR

Note: Please answer all questions with an asterisk (*) if you are seeking $200 or less in assistance. If you are seeking
over $200 in assistance, please answer all questions. Answer N/A to questions that do not apply.

Date*:_______ Current TBS member*? Yes ___ No ___

What are you requesting assistance for? ___ Membership ___ Religious School
If for religious school, which children will be attending? _________________________________________________
How much assistance are you requesting*? ___________________
Applicant’s Name*: __________________________________________________ Birthdate*: ________
Spouse’s Name*: ____________________________________________________ Birthdate*: ________
Dependent Children/Birthdate*
________________________ _______ ___________________________ _________
_______________________ _______ ___________________________ _________
Address*: ___________________________________ City*: _________ State*: ____ Zip*: _______
Home Phone*: ____________________ _______ Cellular Phone: _________________________

FAMILY DATA
What year did you move to Las Vegas? ______________
Marital Status: Single ___ Married ___ Divorced ___ Separated ___ Widowed ___
If divorced, who has legal custody of the children? ______________________________________________________
Others living in your home who are dependent on you? __________________________________________________
Do you rent*? ___ Own? ___ Home? ___ Apartment? ___
Applicant’s occupation*: __________________________________________________________________________
Employer & Address: _____________________________________________________________________________
Supervisor’s Name: ______________________________________________________________________________
How long employed there? ________________________ Business phone: _____________________________
Spouse’s Occupation*: ___________________________________________________________________________
Employer & Address: ___________________________________________________________________________
Supervisor’s Name: _____________________________________________________________________________
How long he/she employed there? ___________________ Business phone: __________________________

(OVER)
 MONTHLY INCOME

TOTAL MONTHLY GROSS HOUSEHOLD INCOME* $ __________________________________

ASSETS (Current Value)

Checking & Savings Accounts $ _________ Real Estate (Home)* $ _________
Other Investments $ _________ Other Personal Property $ _________
List Make/Model/Year of car(s)*:
Car #1 ____________________________________ Car #2 _________________________________
Summer Camps attended by children: ________________________________________________________

MONTHLY EXPENSES

Mortgage/Rent* Childcare Car Repair

$ $ $
Auto Loans* Synagogue due Other Insurance
$ $ $
Other Loans Charity/Contributions Recreation/Cable TV
$ $ $
Medical/Dental Utilities Clothing
$ $ $
Car Insurance Credit Card Pymt. College/Private School
$ $ Tuition $
Food Gasoline Other Expenses
$ $ $

Other extraordinary expenses or special circumstances: Be specific as to expense and anticipated duration of
circumstance. (If more space is need, attach an additional sheet.)*

Are you receiving financial assistance from any other agency? If so, where and how much? *
______________________________________________________________________________________________

In consideration of receiving dues assistance, I agree to assist the Temple in the following ways:

_____ Answering office phones : Days & Times ______________________________________________________

_____ Stuffing envelopes and fliers: Days & Times ___________________________________________________
_____ Making telephone calls to promote upcoming Temple events: Days & Times __________________________
_____ Other : __________________________________________________________________________________

I (we) affirm that the information shown above is accurate. If I (we) receive a fee adjustment, I (we) agree to pay
the remaining sums due in a timely manner. I (we) understand that a fee adjustment is not automatically
renewable and must be reviewed annually.

Applicant’s Signature(s)

NOTE: Please be sure to return your signed application with income verification (current paystub and copy of last year’s
tax return (personal and business).