Aid Request Form – חסדי אפרת

Date*

Last name*

First name*

Teudat Zehut number / Identity number*

Date of birth*

Address*

Home phone*

Cell phone*

Email*

Gender*

Male

Female

Place of employment*

Marital status*

Spouse

Last name*

First name*

Teudat Zehut number / Identity number*

Date of birth*

Address*

Home phone

Cell phone

Email*

Place of employment*

Additional Household Members

Name

Year of birth

T.Z. number

Occupation

Monthly Income

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

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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