Mark Ramer Chesed Center

Leon Mayer Fund Intake Form

*INCOMPLETE APPLICATIONS WILL NOT BE APPROVED
All information will be kept confidential unless we're required to discuss with your referance.

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Spouse Name

Question Title

* 4. Date of Birth

Date / Time

Date

Question Title

* 5. Contact Information

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 6. Cell Phone

Question Title

* 7. Marital Status

Single

Married

Widowed

Divorced

Separated

Question Title

* 8. Number of children at home?

Number

Question Title

* 9. Religious Institution

Question Title

* 10. Religious Leader

Question Title

* 11. Are you or your spouse currently employed:

Yes

Question Title

* 12. If employed, employer name:

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

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)

Question Title

* 15. Reference Name

Question Title

* 16. Reference Phone Number

Question Title

* 17. From whom or how did you hear about the Leon Mayer Fund?

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

Mark Ramer Chesed Center

Leon Mayer Fund Intake Form

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Spouse Name

Question Title

* 4. Date of Birth

Question Title

* 5. Contact Information

Question Title

* 6. Cell Phone

Question Title

* 7. Marital Status

Question Title

* 8. Number of children at home?

Question Title

* 9. Religious Institution

Question Title

* 10. Religious Leader

Question Title

* 11. Are you or your spouse currently employed:

Question Title

* 12. If employed, employer name:

Question Title

* 13. What is your total household income?

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.

Question Title

* 15. Reference Name

Question Title

* 16. Reference Phone Number

Question Title

* 17. From whom or how did you hear about the Leon Mayer Fund?

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.

* 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.