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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Former Spouse Name* First Last Former Spouse Resides* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 AffiliationRabbi 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]
