Contribution Assistance Form

General Information

We are unable to consider your application without answers to ALL of the following questions:

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Marital Status*

If married please include spouses name

Have you previously requested financial assistance?*

Yes
No

Dependent Information

Do you have dependent children?*

Yes
No

Dependent information

Child's First Name	Age	Attends Bonim Preschool (yes/no)	Attends Hebrew School (yes/no)

Are you receiving member discount for Bonim Preschool?*

Yes
No

Are you requesting a scholarship for Religious School?*

Yes
No

Employment Info

Employment information for each adult*

Name	Occupation	Employer

(Click the + sign after employer to create a new line for entering additional adult information)

Total household yearly income, please do not split by person*

PLEASE EXPLAIN THE REASON FOR YOUR REQUEST AND PROVIDE AS MUCH INFORMATION AS POSSIBLE:*

Payment Pledge:*

I/We confirm that I/we would like to be part of the CBI Community and I/we believe that due to our financial circumstances I/we currently require financial assistance from the members of the CBI Community.

I/We understand that the adjustment to my/our annual contribution is based on my/our current situation and pledge to increase our annual contribution as soon as our financial situation improves.

I/We also confirm that all of the information in this application is accurate.

In accepting financial assistance, I/we will consistently make agreed upon payments and if unable to abide by the schedule or terms I/we will contact the Financial Secretary immediately.

The Financial Secretary will review this request and will respond (via email or phone) as quickly as possible.

If necessary, I prefer a call from (choose one):

The best number and time to reach me is: