Financial Hardship Variance Request

Request for Financial Hardship Variance

First Name

Last Name

Address

City

State

Zip

Mobile #

* Please check all that apply

Annual Membership Dues ($2050 family/$1075 individual/$685 associate)Annual Capital Fund ($5000 family/$2500 individual - both over 5 years)Religious School Tuition (varies per grade level)

* Please enter your proposed payment amount(s):

Example: Dues - $000.00/month, Religious School - $000.00/year, etc.

Why are you requesting a financial hardship variance?

Please state any extraordinary expenses:

Should you wish to supply any further information in support of this application (Form 1040, etc.), you can do that here. You are NOT obligated to do so.

Please acknowledge

Please acknowledgeI/We also understand that such fees as Yotair Ivrit (Hebrew Tutoring), Bar/Bat Mitzvah fees, Confirmation fees, Room Usage fees and fees for High Holiday tickets for guests are in addition to the amounts which may be agreed upon and are not subject to adjustment.

I/We further understand that any dues, Capital Fund or Religious School Tuition commitments (financial hardship variance plan) must be current to partake in a life cycle event, i.e., Bar/Bat Mitzvah, Confirmation, etc.

Please acknowledge

Please acknowledgeI/We understand that all payments made monthly must be made either through ACH or a credit card.

Please acknowledge

I/We agree to keep current with the Membership Dues, Capital Fund and Religious School Tuition as adjusted, and will be responsible for all prior amounts.

By selecting the "Submit" button, I/We are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature.