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Application for Dues Reduction 2023
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Please login in to your account before completing this form.
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First Name
Last Name
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Street Address
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Address Line 2
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City
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State
--Select State--
Alabama
Alaska
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District of Columbia
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Maryland
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New Hampshire
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New York
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Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Zip Code
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Home Phone
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Cell Phone
(Applicant)
*
Email (Applicant)
Cell Phone
(Spouse/Partner)
Email (Spouse/Partner)
Dependents
Names and Ages
Employment Information
Applicant's Occupation
Spouse/Partner's Occupation
*
Applicant's Employer
*
Spouse/Partner's Employer
*
Applicant's Business Address
*
Spouse/Partner's Business Address
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Applicant's 2021 Actual Compensation
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Spouse/Partner's 2021 Actual Compensation
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Applicant's Projected 2022 Compensation
(Including salary, wages, bonus, commissions, etc.)
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Spouse/Partner's Projected 2022 Compensation
(Including salary, wages, bonus, commissions, etc.)
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Applicant - Ownership Interest in Business?
Yes
No
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Spouse/Partner Ownership Interest in Business
Please Select One
Yes
No
Household Financial Information
*
Child Support
Paid
Received
Not Applicable
Monthly Child Support Payment
If applicable
Principal Home
Own
Rent
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Principal Home - Monthly Payment - Rent/Mortgage
(Including taxes and insurance)
*
Secondary Home
Own
Rent
Not applicable
Monthly payment - Secondary Home - Rent/Mortgage
(Including taxes and insurance)
Medical Expenses
(Insurance premiums, co-pays, out of pocket)
Car Payments
Click + sign for each vehicle
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Car Make, Model, Year
Monthly Payment
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Lease or Own
Other Significant Financial Obligations
Other Planned or Committed Activities
Private Schools/Colleges - Annual Payment
Private Clubs - Golf, Country, Fitness, etc
Summer Camps
Other
Description of Circumstances - Reason for requesting special consideration
Please explain unusual expenditures or circumstances in detail
Please upload a copy of your past year 2021 Federal Income Tax Return, W-2 forms and a copy of your current year pay stub(s).
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Current Dues and Fees
Shown below are the various membership categories that may be eligible for a dues reduction. Please check the box of the appropriate membership category and then indicate the total amount that you can pay based on your financial situation.
Please note: Only the following dues/fee categories are eligible for special arrangement or adjustment. Other fees such as the Bar/Bat Mitzvah fee, Operational, Security and Utility assessments, and School Books/Activity fee cannot be modified by special arrangement.
If you have previously paid a **Building fund**
to Temple Chaverim or any other synagogue, please call Julie or Vicky at 516-367-6100 for information on receiving a credit on your account for the amount paid previously.
Family Membership (children 3rd grade and older)
Family Membership (children 3rd grade and older)
Annual dues: $2,335: 1st year dues $1167.50 with 50% new member incentive discount.
Utility/Security/Operational assessments total: $375.
Religious School Grades 3-7: $995 first child, $945 for additional children.
Religious School Grades K-2: $450 per child.
Books and Materials: $135 per child.
Tuesday Night Live (grades 8-12): $190 per child.
Sisterhood/Men’s Club: complimentary year one – optional dues of $36 each starting in year two.
Building Fund**: $3,000 – $600 per year over 5 years (years 1-5) $500 discount if paid within the first year of membership.
Total Amount
Single Parent Household
Single Parent Household
Annual dues: $1,610: 1st year dues $805 with 50% new member incentive discount
Utility/Security/Operational assessments total: $375.
Religious School Grades 3-7: $995 1st child, $945 each additional child.
Religious School Grades K-2: $450.
Books and Materials: $135 per child.
Tuesday Night Live (grades 8-12): $190 per child.
Sisterhood/Men’s Club: complimentary year one – optional dues of $36 each starting in year two.
Building Fund**: $3,000 – $600 per year over 5 years (years 1-5) $500 discount if paid within the first year of membership.
Total Amount
Post Bar Mitzvah Family/Empty Nester (Family whose children are older than Bar Mizvah age)
Post Bar Mitzvah Family/Empty Nester (Family whose children are older than Bar Mizvah age)
Annual dues: $2,025: 1st year dues $1013 with 50% new member incentive discount
Utility/Security/Operational assessments total: $375.
Tuesday Night Live (grades 8-12): $190 per child.
Sisterhood/Men’s Club: complimentary year one – optional dues of $36 each starting in year two.
Building Fund ** : $3,000 – $600 per year over 5 years (years 1-5 or years 2-6) $500 discount if paid within the first year of membership.
Total Amount
B'nai Mitzvah Pledge (if applicable)
I/
We agree that we will pay all fees associated with the Bar or Bat Mitzvah of our child/children (including but not limited to the b’nai mitzvah fee, havdallah fee, membership, building fund and religious school tuition reduced by any financial relief granted) in full three months prior to my child’s or children’s Bar or Bat Mitzvah ceremony.
Yes
No
Not applicable
Applicant Statement
I/We understand that, if granted, the dues reduction and/or scholarship is for one year and must be reapplied for annually.
I/We also understand that any unpaid dues and fees from previous years must be paid, and that I/we must be current in my/our dues and fees to participate in life-cycle events (such as baby naming, Bar/Bat Mitzvah, Wedding, Funeral).
I/We further understand that the members of the Dues Reduction Committee will keep my information, adjustment and payment schedule
CONFIDENTIAL
, and I/we agree that I/we
WILL NOT DISCLOSE
the details of my/our adjustment plan to other Temple members.
I/We affirm that the information in this application is correct, and I/we agree to notify the Temple Treasurer or Executive Director in the event that any financial change occurs in the information I/we have provided.
I/We agree to keep current with my/our dues and fees
AS ADJUSTED
, and I/we will be responsible for all prior balances with the Temple.
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Signature of Applicant
*
Date
Signature of Spouse/Partner
Date
Thu, March 28 2024 18 Adar II 5784