Tomchei Shabbos Application

TOMCHEI SHABBOS APPLICATION

PO BOX 481270 Los Angeles, CA 90048

Tel: (323) 851-1000 Fax: (888)503-3783 Completed Applications should be FAXED to 888-503-3783

Date: ______

New

Renew

First Last Date of BirthAge Gender

Applicant Name: ______/___/______

Spouse Name: ______/___/______

Address: ______Apt:______City:______Zip:______Home Tel. Number: Cell Phone (female): Cell Phone (male): E-mail Address:

(_____)______-______(____)_____-______(____)_____-______

@______. ____

Children Living at Home

(List Additional children living at home on a separate paper)

Name / Gender / Age / Date of Birth / Current School/Work / Clothing Size
1.______/ ______/ ______/ ______/ ______/ ______
2. ______/ ______/ ______/ ______/ ______/ ______
3.______/ ______/ ______/ ______/ ______/ ______
4.______/ ______/ ______/ ______/ ______/ ______
5.______/ ______/ ______/ ______/ ______/ ______
6.______/ ______/ ______/ ______/ ______/ ______

Children NOT Living at Home

Name: ______Gender _____ Date of Birth ______School ______Name: ______Gender _____ Date of Birth ______School ______

Other Dependants Living With You

Name: ______Gender _____ Date of Birth ______Relationship ______Name: ______Gender _____ Date of Birth ______Relationship ______

*TO BE FILLED OUT BY SPONSORING RABBI ONLY
Applications that are not signed by a sponsoring Rabbi will not be processed.
Rabbi’s Name ______Rabbi’s Cell Number ______
Synagogue’s Name ______Telephone Number ______
Synagogue’s Address ______City______Zip ______
I personally know the ______family and verify that their situation requires the assistance of Tomchei Shabbos.
I have read all 3 pages and acknowledge that the information is accurate & correct.
This family requires assistance due to: ______
______
______I am aware that I will be contacted in order to verify the status of the family’s needs.
______Rabbi’s Name (print) Rabbi’s Signature Today’s Date

Last Name:______

Financial Information

*Employment Information (Male)
Type of Work______Social Security Number ______-______-______
Employer ______Years on Job______
Work Address ______City______Zip______Tel. Number (____) ______-______
Salary $______Weekly Monthly (Hourly Wage ______Avg. Weekly Hours______)
If not employed: Reason Not Employed: ______
Not Employed Since: ______Type of Work Looking for: ______
Do you have a: Driver’s License Car Auto Insurance

*Employment Information (Female)
Type of Work______Social Security Number ______-______-______
Employer ______Years on Job______
Work Address ______City______Zip______Tel. Number (____) ______-______
Salary $______Weekly Monthly (Hourly Wage ______Avg. Weekly Hours______)
If not employed : Reason Not Employed: ______
Not Employed Since: ______Type of Work Looking for: ______
Do you have a: Driver’s License Car Auto Insurance

*Others living with you and earning an income:
Name: ______Relationship: ______Date of Birth______Type of Work: ______
Employer______Work #:______Monthly Income: ______
Name: ______Relationship: ______Date of Birth______Type of Work: ______
Employer______Work #:______Monthly Income: ______
*Government Assistance
Welfare $______SSI $______HUD $______
WIC $______Section 8 $______Other $______
Have you applied? ______Where? ______When? ______
Reason Not Receiving Assistance ______
Reason for Not Applying ______

Referred By: ______Tel. #______

Last Name:______

Special Needs

Vegetarian Non-Fat Milk Kosher Only Other:______

Are you Allergic to any of the following: Eggs Dairy Wheat/Gluten Please include any relevant additional information (financial, family situation, medical concerns, employment situation etc.) ______

______

______

______

______

______

*Monthly Expenses – (If charges are annual please average the monthly payment)
Rent Mortgage$______Health Insurance:$______
House or Apt.: Life Ins.:$______
How many bedrooms: ______Home/Rental Ins.: $______
Gas Company:$______Car Payments: $______
Water/Power: $______Car Insurance:$______
Telephone (landline):$______Gasoline: $______
Cell Phone:$______Car Repair, Etc.:$______
DSL/Cable:$______MonthlyCredit CardPayment: $______
Other Household Expenses: $______(Total Credit Card Debt:______))
Tuition: $______Monthly Medical Expense: $______Food: $______(Total Medical Expense Debt:______)
Misc.: $______Other Debts:$______
Clothing:$______Total Monthly Expenses:$______

OFFICE USE ONLY- PLEASE DO NOT WRITE IN THIS SPACE Date: Authorized Tomchei Signature:

Vaad Tomchei Shabbos Notes:

1Revised 01/2014