Step 1 of 10 10% The DMF continues its mission to help individuals and families within our community. The following questionnaire is for us to gain a better understanding of you. It will allow the DMF to better cater the programs, sales, discounts and services which we provide. DMF is actively seeking to offer more programs, your responses will help us identify where there are needs. We understand that these questions and responses are highly confidential in nature. All information will remain strictly confidential. We understand many face financial stresses, we also understand there are many variables to everyone’s unique situation. Please take the time and answer as completely and accurately as possible. Your honest feedback and responses to this questionnaire is much appreciated. With appreciation, The DMF Marital Status* Married Widower/Widow Separated/Divorced Single Name* RabbiRebitzenMr.Mrs.Ms. Prefix First Last Age*18-2425-3435-4445-5455-6465-7475 or AboveHusband's Name* RabbiDr.Mr. Prefix First Last Husband's Age*Select18-2425-3435-4445-5455-6465-7475 or AboveWife's Name* Mrs.RebitzenDr. Prefix First Wife's Age*Select18-2425-3435-4445-5455-6465-7475 or AboveLegal Name RabbiRebitzenMr.Mrs.Ms. Prefix First Middle Last Husband's Legal Name First Wife's Legal Name First Last Maiden Name* Former Spouse Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Home PhoneEmail* Cell Phone*Husband's Cell Phone*Husband's Email Wife's Cell Phone*Wife's Email Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Former Spouse Resides* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Preferred Contact Method Cell Phone/Text Spouse Cell Phone/Text Email Spouse Email Any If any of these methods are NOT checked regularly/or you don't have access please check them off. Otherwise check off "No Preference"* No Preference Email Mobile (Text) Mobile (WhatsApp) Do you have children?* Yes No How many children do you have?*How many children do you have at home?*UntitledFirst ChoiceSecond ChoiceThird ChoiceChildren Living at home Information*If not applicable please write N/ANameBirth MonthBirth YearGenderSchool JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember2012201120102009200820072006200520042003200220020001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978 197719761975197419731972197119701969196819671966196519641963196219611960MaleFemale Do you have any children with Special Needs?* Yes No Annual CostsPlease describe Approximately costs per year for their care? Do you have any married children?* Yes No How many married children do you have?Married Children Information*If not applicable please write N/AHusband and Wife's First and Last NameCity, State where they reside Do your married children receive financial support from you? Yes No Total annual support you provide for your married children?* Are there others who are financially dependant on you?*This includes Elderly Parents, etc. Yes No Dependant Information*First and Last NameRelationship to you If not applicable please write N/AAnnual AssistanceApproximately how much annually do you provide? Employment* Employed Full-Time Employed Part-Time Self-Employed Student Recently Unemployed/Terminated Currently Not Working Husband's Employment* Kollel Employed Full-Time Employed Part-Time Self-Employed Student Recently Unemployed/Terminated Currently Not Working Occupation* Employer* Kollel InformationKollel NameAttending Kollel Since (Year) Husbands's School InformationSchool AttendingDegree PursuingAnticipated Graduation Date Previous Occupation* For how long been Unemployed?* Most Recent Employer* Wife's Employment* Employed Full-Time Employed Part-Time Self-Employed Student Recently Unemployed/Terminated Currently Not Working Wife's Schooling InformationSchool NameDegree PursuingExpected Graduation Date Schooling InformationSchool NameDegree PursuingExpected Graduation Date Wife's Occupation* Wife's Employer* Wife's Previous Occupation* For how long has been Unemployed?* Wife's Most Recent Employer* What best describes your total household annual income?*Under $50,000$50,000-$100,000$100,000-$125,000$125,000-$150,000$150,000-$175,000$175,000-$200,000$200,000-$225,000$225,000-$250,000Above $250,000Please include all parsonage and untaxable income. As with all questions on this questionnaire, all responses are kept strictly confidential.Do you receive any support from your former spouse?* Yes No What is the support monthly?* Former Spouse Other Obligations Besides for monthly monetary support, does your former spouse share other financial responsibilities. for example Tuition, Camp, Simchos, Etc.Do you receive consistent financial assistance?*This includes family, communal, friends etc. support. Consistent support is defined as repetitive financial assistance from sources outside of your employment. Yes No Total Consistent support received Annually* Do you own or rent your Home/ Apartment Own Rent What is your monthly expense for your Home/ Apartment* Please list major annual recurring expenses*For example, Tuition, Car payments, Medical, therapy, housekeeping etc.Name of ExpenseAnnual Cost Please list major non-recurring expenses in the last 3 yearsFor example, medical, simchaName of ExpenseCostYear of occurence Please list any debt you may haveDebtorAmount owed Describe your need* Select All One Time Assistance Temporary/ Periodic Assistance Ongoing Struggles Mostly Summer Assistance Mostly Yom Tov Assistance Therapy/ Medical Assistance What Government Assistance do you currently receive?*Choose all that apply SNAP (Food Stamps) Medicaid Section 8 (HUD) WIC Other Government/Community Benefits None From Whom/ Which Organization? In an effort to better cater our programs to assist you and your family, briefly describe which of our current programs or programs you would like to see us intoduce that would be most beneficial for your needs.*For example sales or discounts on clothing and food. We welcome any ideas.Please share any pertinent information you wish to share with us regarding your needs.* Shul Affiliation Rabbi or Advocate Name* Phone Number*Email Opt-in for Email Correspondence I would like to receive email correspondence regarding any assistance programs that would be beneficial for me.Confirmation of Information I/We hereby confirm that the information provided herein is accurate, correct and complete.Davis Memorial Fund 25 Lawrence Avenue Lawrence, NY 11559 P. 516-295-0296 E. [email protected]
