Aid Request Form – חסדי אפרת

Date*

DD סלאש MM סלאש YYYY

What help are you presently requesting?

Please select from options below

Loan

Scholarship

Grant

Weekly Food Basket

Help for holidays

Financial Guidance

Other

Last name*

First name*

Teudat Zehut number / Identity number*

Please Upload Teudat Zehut/ Passport including attachment.*

Max. file size: 256 MB.

This is a required field. Without this upload, the form cannot be completed.

Date of birth*

DD סלאש MM סלאש YYYY

Home phone*

Cell phone*

Address*

Email*

Gender*

Male

Female

Place of employment*

Description of job

Marital status*

Married

Single

Divorced

Widowed

Separated

SPOUSE

Last name*

First name*

Teudat Zehut number / Identity number*

File*

Max. file size: 256 MB.

Date of birth*

MM סלאש DD סלאש YYYY

Home phone

Cell phone

Address*

Email*

Place of employment*

Additional Household Members

Name

Year of birth

T.Z. number

Occupation

Monthly Income in NIS

Lives at home

YOUR MONTHLY INCOME (in NIS)

Workplace net income*

Bituah Leumi (child allowance, disability payments)

Mezonot (child support)

Monthly help from family or friends

Monthly income from abroad

Other income (rental, pensions, investments)

SPOUSE'S MONTHLY INCOME (in NIS)

Workplace net income*

Bituah Leumi (child allowance, disability payments)

Mezonot (child support)

Monthly help from family or friends

Monthly income from abroad

Other income (rental, pensions, investments)

ESTIMATED MONTHLY EXPENSES (in NIS)

Rent*

Education*

Car expenses*

[gas, insurance, upkeep]

Mortgage*

Chugim*

Clothing*

Insurance*

Medical*

Arnona / Water / Security*

Groceries*

Electricity*

Maintenance*

Other

Upload Files

Please include paystubs, bank account statements, Bituah Leumi certifications, for the last three months

שחרר קבצים כאן או

Max. file size: 256 MB.

DISCOUNTS

Do you receive an Arnona discount?

Yes

How much is your Arnona bill after the discount?*

What percentage is the discount?

Do you receive a tuition discount?

Yes

How much is your tuition after the discount?*

What percentage is the discount?

Please list assets owned in Israel and abroad (real estate, bank accounts, etc.).

House/Apartment

Car/s

Other/s

Do you have any outstanding loans? If yes, please specify.

Do you have any outstanding bank loans?”

Yes

Total loan

From Banks

Left to reimburse

From Banks

Do you have any outstanding credit card loans?”

Yes

Left to reimburse

From Credit Cards

Total loan

From Credit Cards

Do you have any outstanding family loans?”

Yes

Total loan

From Family

Left to reimburse

From Family

Do you have any outstanding other loans?”

Yes

Total loan

From Others

Left to reimburse

From Others

Do you have any outstanding bills (e.g., credit card debt, arnona, electricity, dental or medical, home repair)?

Yes

Outstanding Bills

Bill

Amount in NIS

Do you have a file with the Social Services Department?*

Yes

Hidden

Name of assigned Social Worker

Please sign a Waiver of Confidentiality so we can work together with the Social Services Department

I hereby authorize the Director of the social services department, or anyone empowered by him, to receive from or share information about myself or any of my family members, with the Chasdei Efrat fund, and I waive all obligations of confidentiality from him.

Name*

Teudat Zehut Number*

Signature*

What is the reason you are turning to us for help specifically at this time?

(Please attach any supporting documents that might be relevant, such as medical opinions or legal bills)

File

Max. file size: 256 MB.

What kind of help are you asking for?*

What other organization/s have you turned to for help?*

Have you received financial guidance from a service such as Mekimi or Pa'amonim?*

Yes

Hidden

Name of assigned Counsellor

Phone

Please sign a Waiver of Confidentiality so we can work together with the above counselor.

I hereby authorize the Financial Counselor named above, or anyone empowered by him, to receive from or share information about myself or any of my family members, with the Chasdei Efrat Fund, and I waive all obligations of confidentiality from him.

Name*

Teudat Zehut Number*

Signature*

Hidden

Consent*

I /hereby declare, that all the information above is accurate.

Signature of Applicant*

Signature of Spouse*

Date

MM סלאש DD סלאש YYYY

Comments

שדה זה מיועד למטרות אימות ויש להשאיר אותו ללא שינוי.

FINANCIAL ASSISTANCE FORM

NOTE

SPOUSE

YOUR MONTHLY INCOME (in NIS)

SPOUSE'S MONTHLY INCOME (in NIS)

ESTIMATED MONTHLY EXPENSES (in NIS)

DISCOUNTS

Please list assets owned in Israel and abroad (real estate, bank accounts, etc.).

Do you have any outstanding loans? If yes, please specify.

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