Leon Mayer Fund Intake Form

Please fill out this form and click submit.

Please note that incomplete applications will not be approved

Personal Information

Name

Spouse Name

Birthdate

Home Phone

Cell Phone

Address

Family Information

Marital Status

Please select one option.

Single Married Divorced Separated Widowed

Number and Ages of Children (at home/unmarried)

Religious Institution

Religious Leader

Phone Number

Income

Are you or your spouse currently employed?

Please select one option.

Yes No

If employed, employer name

Are you a student or in Kollel?

Please select one option.

Yes No

Stipend

Total Household Income

Please select one option.

Less than $20,000 $20,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 - $149,999 $150,000 or more

Do your receive (check all that apply) Please note: Checking any of the boxes below will not disqualify you from receiving assistance from the Leon Mayer Fund

Please select all that apply.

SSI SNAP Welfare Medicaid Section 8 None of the above

Names of organizations that give/gave assistance:

Please select all that apply.

Davis Memorial Fund Tomchei Shabbos Achiezer JCCRP Gural JCC Other None of the above

If Other, please specify

Reference

Reference Name

Reference Phone Number

Briefly explain the circumstances which have caused you to seek assistance.

By checking this box, I am giving the Leon Mayer Fund and its employers permission to verify the information provided. I understand that any incorrect information can cause my application to be denied.

Please select all that apply.

I understand

To set up an appointment please call our office. 516-561-6868 ext. 102

Description

Please fill out this form and click submit.

Leon Mayer Fund Intake Form

Description

Please Fix the Following