For financial assistance please fill out this form and press “send” to submit.If you have any questions, please write to us at chasdei.efrat@gmail.comThank you. "*" אינדוקטור שדות חובה שלב 1 מתוך 4 25% Date* MM סלאש DD סלאש YYYY Last name* First name* Teudat Zehut number / Identity number*Date of birth* MM סלאש DD סלאש YYYY Address* Home phone*Cell phone*Email* Gender* Male Female Place of employment* Marital status* Married Single Divorced Widowed Separated SpouseLast name* First name* Teudat Zehut number / Identity number*Date of birth* MM סלאש DD סלאש YYYY Address* Home phoneCell phoneEmail* Place of employment* Additional Household MembersNameYear of birthT.Z. numberOccupationMonthly IncomeLives at home Add Remove Your monthly income (in NIS)Workplace net incomeBituah Leumi (child allowance, disability payments)Mezonot (child support)Monthly help from family or friendsMonthly income from abroadOther income (rental, pensions, investments)Spouse's monthly income (in NIS)Workplace net incomeBituah Leumi (child allowance, disability payments)Mezonot (child support)Monthly help from family or friendsMonthly income from abroadOther income (rental, pensions, investments)Estimated monthly expenses (in NIS)RentEducationCar expenses[gas, insurance, upkeep]MortgageChugimClothingInsuranceMedicalArnona / Water / SecurityGroceriesElectricityMaintenanceOtherUpload FilesPlease include paystubs, bank account statements, Bituah Leumi certifications, for the last three months שחרר קבצים כאן או בחירת קבצים Max. file size: 256 MB. DiscountsDo you receive an Arnona discount? Yes No How much is your Arnona bill after the discount?*What percentage is the discount?Do you receive a tuition discount? Yes No 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 No Total loanFrom BanksLeft to reimburseFrom BanksDo you have any outstanding credit card loans?” Yes No Total loanFrom Credit CardsLeft to reimburseFrom Credit CardsDo you have any outstanding family loans?” Yes No Total loanFrom FamilyLeft to reimburseFrom FamilyDo you have any outstanding other loans?” Yes No Total loanFrom OthersLeft to reimburseFrom OthersDo you have any outstanding bills (e.g., credit card debt, arnona, electricity, dental or medical, home repair)? Yes No Outstanding BillsBillAmount in NIS Add RemoveDo you have a file with the Social Services Department?* Yes No HiddenName 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)FileMax. file size: 256 MB. What kind of help are you asking for?Please select from options below Loan Scholarship Grant Weekly Food Basket Help for holidays Financial Guidance Other 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 No HiddenName of assigned Counselor PhonePlease 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*HiddenConsent* I /hereby declare, that all the information above is accurate.Signature of Applicant*Signature of Spouse*Date MM סלאש DD סלאש YYYY Δ