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Special Dues Request - Synagogue Membership

2024-2025

Please complete this form to apply for dues assistance at Valley Beth Shalom. All information submitted is kept private and confidential. If you have any questions, please don't hesitate to reach out to Karen Benyishay, VBS Sat 818-530-4018, or by email kbenyishay@vbs.org.

Member Information

Member 1:

First Name:

Last Name:

Email:

Cell Phone:

Employment (select one):

Full TimePart TimeUnemployed

Employer Information (if unemployed, please write N/A in the following fields):

Occupation:

How long have you worked there (approximately)?

Business Phone:

Member 2 (if applicable):

First Name:

Last Name:

Email:

Cell Phone:

Employment(select one):

Full TimePart TimeUnemployed

Employer Information (if unemployed, please write N/A in the following fields):

Occupation:

How long have you worked there (approximately)?

Business Phone:

Address:

Unit:

City:

State:

Zip Code:

Child/Children Information

How many children do you have?

One Child

First Name (of child):

Last Name (of child):

Age:

What school does this child attend (select all that apply)?

VBS ECCVBS Day SchoolVBS ECLC (Hebrew School)Other School

If 'other', what school is your child attending?

Two Children:

Child 1:

First Name (of child):

Last Name (of child):

Age:

What school does this child attend (select all that apply)?

VBS ECCVBS Day SchoolVBS ECLC (Hebrew School)Other School

If 'other', what school is your child attending?

Child 2:

First Name (of child):

Last Name (of child):

Age:

What school does this child attend (select all that apply)?

VBS ECCVBS Day SchoolVBS ECLC (Hebrew School)Other School

If 'other', what school is your child attending?

Three Children:

Child 1:

First Name (of child):

Last Name (of child):

Age:

What school does this child attend (select all that apply)?

VBS ECCVBS Day SchoolVBS ECLC (Hebrew School)Other School

If 'other', what school is your child attending?

Child 2:

First Name (of child):

Last Name (of child):

Age:

What school does this child attend (select all that apply)?

VBS ECCVBS Day SchoolVBS ECLC (Hebrew School)Other School

If 'other', what school is your child attending?

Child 3:

First Name (of child):

Last Name (of child):

Age:

What school does this child attend (select all that apply)?

VBS ECCVBS Day SchoolVBS ECLC (Hebrew School)Other School

If 'other', what school is your child attending?

Four Children:

Child 1:

First Name (of child):

Last Name (of child):

Age:

What school does this child attend (select all that apply)?

VBS ECCVBS Day SchoolVBS ECLC (Hebrew School)Other School

If 'other', what school is your child attending?

Child 2:

First Name (of child):

Last Name (of child):

Age:

What school does this child attend (select all that apply)?

VBS ECCVBS Day SchoolVBS ECLC (Hebrew School)Other School

If 'other', what school is your child attending?

Child 3:

First Name (of child):

Last Name (of child):

Age:

What school does this child attend (select all that apply)?

VBS ECCVBS Day SchoolVBS ECLC (Hebrew School)Other School

If 'other', what school is your child attending?

Child 4:

First Name (of child):

Last Name (of child):

Age:

What school does this child attend (select all that apply)?

VBS ECCVBS Day SchoolVBS ECLC (Hebrew School)Other School

If 'other', what school is your child attending?

Income Information

Adjusted GROSS INCOME from your most recent (2023) tax return:

Do you own or hold an interest in any of the following (please select all that apply)?

Business (Sole Proprietorship, Corporation, LLC etc.)Estate(s) and/or Trust(s)NoneRental Property

If you earn net income from such sources (that is NOT listed in your AGI), please list total amount here:

Do you have any Social Security benefits that are not taxed (ex: SSI)? If yes, please indicate amount:

Workers Compensation or Disability Income, please list total amount below:

Welfare and/or AFDC/ADC? If yes, please indicate amount:

Non-taxable interest & dividends? If yes, please indicate amount:

Do you receive child support? If yes, please indicate amount (you can list monthly or annually):

Do you have any other sources of income (not represented in the questions above)? If yes, please explain.

Do you anticipate your 2024 income to be different than your 2023 income? If yes, what are the circumstances? Please explain below.

What is your family's expected total annual income for 2024 (including all sources listed above)?

Expenses

Home

Do you rent or own your home?

RentOwn

How long have you owned your home? (Approximately)

What is your monthly rent or mortgage payment (if mortgage, please include both principal & interest)?

If owned, what is the estimated net equity value of your home (the market value minus the mortgage balance):

Do you own a second home?

NoYes

What is the net equity of the second home?

Credit Cards

Total amount of credit card debt (Please include total amount of debt on all credit cards combined. Only include balances carried forward/not paid off):

Total monthly payment(s) on line(s) of credit:

Vehicles

How many vehicles do you own/lease (total)?

One Vehicle

Vehicle 1:

Vehicle 1: Make, Model & Year

Vehicle 1: Do you lease or own?

LeaseOwn

Vehicle 1: Monthly Payment Amount:

Two Vehicles

Vehicle 1:

Vehicle 1: Make, Model & Year

Vehicle 1: Do you lease or own?

LeaseOwn

Vehicle 1: Monthly Payment Amount:

Vehicle 2:

Vehicle 2: Make, Model & Year

Vehicle 2: Do you lease or own?

LeaseOwn

Vehicle 2: Monthly Payment Amount:

Three Vehicles

Vehicle 1:

Vehicle 1: Make, Model & Year

Vehicle 1: Do you lease or own?

LeaseOwn

Vehicle 1: Monthly Payment Amount:

Vehicle 2:

Vehicle 2: Make, Model & Year

Vehicle 2: Do you lease or own?

LeaseOwn

Vehicle 2: Monthly Payment Amount:

Vehicle 3:

Vehicle 3: Make, Model & Year

Vehicle 3: Do you lease or own?

LeaseOwn

Vehicle 3: Monthly Payment Amount:

Four Vehicles

Vehicle 1:

Vehicle 1: Make, Model & Year

Vehicle 1: Do you lease or own?

LeaseOwn

Vehicle 1: Monthly Payment Amount:

Vehicle 2:

Vehicle 2: Make, Model & Year

Vehicle 2: Do you lease or own?

LeaseOwn

Vehicle 2: Monthly Payment Amount:

Vehicle 3:

Vehicle 3: Make, Model & Year

Vehicle 3: Do you lease or own?

LeaseOwn

Vehicle 3: Monthly Payment Amount:

Vehicle 4:

Vehicle 4: Make, Model & Year

Vehicle 4: Do you lease or own?

LeaseOwn

Vehicle 4: Monthly Payment Amount:

Medical

Health insurance premiums paid monthly (total):

Average monthly out-of-pocket medical expenses - including dental & mental health - not paid by insurance (total):

Education

Total education expenses (ECC, K-12, college, graduate school) - monthly payments or annual amount:

Monthly child/day care expenses (approximately):

Monthly child support payments, if applicable (ONLY applies to parent or guardian paying child support):

Key Assets & Liabilities

Value of cash, savings and/or checking accounts (total combined value):

Value of stock, bond investments, mutual funds and/or CD's (total combined value):

Value of retirement plan assets (401(k), 403b, pensions and/or IRA's (total combined value):

Request

Unfortunately, VBS does not have sufficient funds to fulfill all special dues requests. The committee tries their best to help as many members as possible. Thank you for your understanding and support!

Please describe in detail the reasons for your request for special dues:

Please list the amount of temple dues that you are able to pay:

Please list the amount of ECLC tuition you are able to pay (if applicable):

Affirmation

To my/our best knowledge, the information provided in this application is true and correct. Please sign (type First & Last name) below to affirm:

Contact Information