The Temple-Tifereth Israel a Jewish Reform Synagogue
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Give
Confidential Dues Adjustment Form
CONFIDENTIAL Dues Adjustment Form
Please fill out this form in full.
Your Temple account number
*
Member #1
Member #1 - Your Full Name
*
First
Last
Member #1 - Your Contact Phone Number with Area Code
Member #1 - Your Email Address
*
Enter Email
Confirm Email
Member #1 - Your Employment Status
*
Full Time
Part Time
Unemployed
Retired
Member #1 - Employer Name (if employed)
Member #1 - Gross Annual Income
*
Member #2
Member #2 - Your Full Name
First
Last
Member #2 - Your Email Address
Enter Email
Confirm Email
Member #2 - Your Contact Phone Number with Area Code
Member #2 - Your Employment Status
Full Time
Part Time
Unemployed
Retired
Member #2 - Employer Name (if employed)
Member #2 - Gross Annual Income
Please List the Names of All Dependents (if applicable)
Dependent #1 - Full Name
First
Last
Dependent #1 - Age
Please enter a value between
0
and
100
.
Dependent #1 - Enrolled in Temple Learning Center?
Yes
No
Dependent #2 - Full Name
First
Last
Dependent #2 - Age
Please enter a value between
0
and
100
.
Dependent #2 - Enrolled in Temple Learning Center?
Yes
No
Dependent #3 - Full Name
First
Last
Dependent #3 - Age
Please enter a value between
0
and
100
.
Dependent #3 - Enrolled in Temple Learning Center?
Yes
No
Dependent #4 - Full Name
First
Last
Dependent #4 - Age
Please enter a value between
0
and
100
.
Dependent #4 - Enrolled in Temple Learning Center?
Yes
No
Dependent #5 - Full Name
First
Last
Dependent #5 - Age
Please enter a value between
0
and
100
.
Dependent #5 - Enrolled in Temple Learning Center?
Yes
No
A Little Bit More
Extraordinary expenses:
Please explain the reason(s) why you are requesting a dues adjustment:
*
Adjusted dues rate you are requesting:
*
