Mark Ramer Chesed Center Leon Mayer Fund Intake Form *INCOMPLETE APPLICATIONS WILL NOT BE APPROVEDAll information will be kept confidential unless we're required to discuss with your referance. OK Question Title * 1. First Name OK Question Title * 2. Last Name OK Question Title * 3. Spouse Name OK Question Title * 4. Date of Birth Date / Time Date OK Question Title * 5. Contact Information Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address * Phone Number * OK Question Title * 6. Cell Phone OK Question Title * 7. Marital Status Single Married Widowed Divorced Separated OK Question Title * 8. Number of children at home? Number OK Question Title * 9. Religious Institution OK Question Title * 10. Religious Leader OK Question Title * 11. Are you or your spouse currently employed: Yes No OK Question Title * 12. If employed, employer name: OK Question Title * 13. What is your total household income? Less than $20,000 $20,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $149,999 $150,000 or More OK Question Title * 14. Do you 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. SSI SNAP Welfare Medicaid Section 8 Davis Memorial Fund Tomchei Shabbos Achiezer JCCRP Gural JCC Nothing Other (please specify) OK Question Title * 15. Reference Name OK Question Title * 16. Reference Phone Number OK Question Title * 17. From whom or how did you hear about the Leon Mayer Fund? OK Question Title * 18. 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. I Understand OK NEXT
