All submitted information will remain confidential. * Indicates a required fieldMarital Status* Married Widower/Widow Separated/Divorced Single Applicant's Name* RabbiRebitzenMr.Mrs.Ms. Prefix First Last Husband's Name* RabbiRebitzenMr.Mrs.Ms. Prefix First Last Wife's Name* RabbiRebitzenMr.Mrs. Prefix First Maiden Name Applicant's Legal Name RabbiRebitzenMr.Mrs.Ms. Prefix First Middle Last Email* Home PhoneCell Phone*Maiden Name* Spouse Cell PhoneSpouse 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 Name* First Last Former Spouse Resides* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Do you have children that are financially dependant on you?* No Yes How many children do you have?*Children Information*NameBirth Month & YearGenderSchool If not applicable please write N/APreferred 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) Employment* Employed Full-Time Employed Part-Time Self-Employed Recently Unemployed/Terminated Currently Not Working Occupation* Previous Occupation* How long have you been Unemployed?* Employer* Most Recent Employer* Spouse Employment* Employed Full-Time Employed Part-Time Self-Employed Recently Unemployed/Terminated Currently Not Working Spouse Occupation* Spouse Previous Occupation* How long has your Spouse been Unemployed?* Spouse Employer* Spouses's Most Recent Employer* Describe the assistance you require* Select All One Time Assistance Temporary/ Periodic Assistance Ongoing Struggles Mostly Summer Assistance Mostly Yom Tov Assistance Therapy/ Medical Assistance Do you own or rent your Home/ Apartment* Own Rent What is your monthly expense for your Home/ Apartment* Do you receive any support from your former spouse?* Yes No What is the support monthly?* Briefly describe your need:*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? Shul Affiliation Rabbi or Advocate Advocate can be a Rabbi, Therapist, Counselor, or Community Advocate or a Good Friend/Neighbor who is intimately involved in your situationRabbi or Advocate Name* Phone Number*Email Please share any pertinent information you wish to share with us as we review your application for assistance.How did you hear about the Davis Memorial Fund?*Davis Memorial Fund 25 Lawrence Avenue Lawrence, NY 11559 P. 516-295-0296 E. [email protected]
