2021-22 Dues Arrangement Form

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Every member is valued by Netivot Shalom. We understand that full dues may be beyond the financial capacity of some in our community. Dues arrangements are worked out individually each year, based on the information provided on the form below. All information is held in strict confidence by the Dues Committee. Thank you for your commitment to Netivot Shalom.

Even though you will be able to make an immediate payment using this form, your pledge is not final until approved by the Dues Committee. We will inform you once your pledge has been approved.

For assistance please contact our Office & Rabbinic Assistant, ra@netivotshalom.org.

Member 1 Information

Member 2 Information

Member 1 First Name

Member 2 First Name

Member 1 Last Name

Member 2 Last Name

Member 1 Cell Phone

Please use this format: 000-000-0000.

Member 2 Cell Phone

Please use this format: 000-000-0000.

Member 1 Email Address

Member 2 Email Address

* Residence Status

Other

If "Other," please explain

Member 1 Income

Member 2 Income

Member 1 Annual Income (Gross)

Member 2 Annual Income (Gross)

Member 1 Occupation

Member 2 Occupation

(Please include college age dependents.)

Dependent 1 Name

Grade in Fall of 2021

Name of School Attending

Dependent 2 Name

Grade in Fall of 2021

Name of School Attending

Dependent 3 Name

Grade in Fall of 2021

Name of School Attending

Dependent 4 Name

Grade in Fall of 2021

Name of School Attending

Any other individuals living at home?

Relationship to you

Please share any circumstances you would like the Dues Arrangement Committee to consider. These may include housing, health or educational expenses, projections of future income or anything else:

I/we am honored to make my/our annual dues pledge for 2021-2022 in the following amount:

* My/our annual dues pledge for 2021-2022:

Please enter the amount.

Once you "Submit" at the bottom and move onto the payment page, you will have the option to select one of the following payment plans:

* Bill to account - the amount pledged will be billed to your account (If you would like to pay by check, please use this option)

* Pay by credit card - a convenience fee will be added

* Pay by Echeck (ACH, automatic deductions from your bank account) - If you can’t pay your pledge in one lump-sum payment, we ask that you pay either by credit card or by Echeck, as that greatly lowers our administrative burden.

Note: Even though you will be able to make an immediate payment using this form, your pledge is not final until approved by the Dues Committee. We will inform you once your pledge has been approved.

In the drop down menus below, please select the CNS programs in which you plan on enrolling your child/ren

Netivot Educational Programs (child 1)

Netivot Educational Programs (child 2)

Netivot Educational Programs (child 3)

Netivot Educational Programs (child 4)

Signature

By typing my name in the box below, I confirm that I regard financial consideration as a temporary situation and acknowledge that when my financial situation improves, I will return to a standard dues structure.

Wed, January 19 2022 17 Shevat 5782