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    Fee Adjustment Form

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    Temple Beth Sholom
    - The document is an application for membership and/or religious school fee adjustment from Temple Beth Sholom in Las Vegas, Nevada. - It requests personal and financial information such as income, expenses, assets, employment details, and amount of assistance being requested. - The applicant must provide income verification like current pay stubs and tax returns if requesting over $200 in assistance.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF or read online from Scribd

    Fee Adjustment Form

    Uploaded by

    Temple Beth Sholom
    103 views2 pages
    - The document is an application for membership and/or religious school fee adjustment from Temple Beth Sholom in Las Vegas, Nevada. - It requests personal and financial information such as income, expenses, assets, employment details, and amount of assistance being requested. - The applicant must provide income verification like current pay stubs and tax returns if requesting over $200 in assistance.

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    - The document is an application for membership and/or religious school fee adjustment from Temple Beth Sholom in Las Vegas, Nevada. - It requests personal and financial information such as income, expenses, assets, employment details, and amount of assistance being requested. - The applicant must provide income verification like current pay stubs and tax returns if requesting over $200 in assistance.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF or read online from Scribd
    Download as pdf
    103 views2 pages

    Fee Adjustment Form

    Uploaded by

    Temple Beth Sholom
    - The document is an application for membership and/or religious school fee adjustment from Temple Beth Sholom in Las Vegas, Nevada. - It requests personal and financial information such as income, expenses, assets, employment details, and amount of assistance being requested. - The applicant must provide income verification like current pay stubs and tax returns if requesting over $200 in assistance.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF or read online from Scribd
    Download as pdf
    of 2

    Temple Beth Sholom

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

    APPLICATION FOR MEMBERSHIP AND/OR RELIGIOUS SCHOOL FEE ADJUSTMENT


    CONFIDENTIAL

    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: __________________________
    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 _________________________________

    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? *
    ______________________________________________________________________________________________

    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).

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