Membership Reporting Form 2020-21

Membership Reporting Form 2020-21
Date *

Month Day Year
Date
Synagogue Name *
City *
State/Province *
Part One: Membership Information
Number of member units paying $500 or more in membership dues *
Number of member units paying between $191 and $499 in membership dues *
Number of member units paying under $191 in membership dues *
Total Number of membership units *
Dues Calculation:
Member units paying $500 or more (USCJ dues $74.50/unit) Line 2 above X $74.50 = *
Member units paying $191-$499 (USCJ dues $37.25/unit) Line 3 above X $37.25 = *
Member units paying under $191 (USCJ dues $0.00/unit) Line 4 above X $0.00 = *
Total Dues *
Sum of 3 lines above.
Part Two: Dues Payment Plan Options
Please check one option below: *

Paid in full by December 31, 2020 and will not be providing our membership list. Paid in full by December 31, 2020 and we will also submit our membership mailing/email list by years end to receive the early dues 2.5% payment discount. Quarterly payments – to be received by 15th of the months August, October, January and April. Ten (10) equal payments – initial payment in July 2020 and final payment in April 2021. Twelve (12) equal payments – July 2020 to June 2021.
How would you like to pay: *

Mail a check to USCJ Automatic payment plan (ACH or wire transfer) - we will contact you to give you more information including setting this up online Credit card payment which can be made online or please contact us to give us your information
The following questions are included to help us better serve our affiliated synagogues. This information is greatly appreciated.
Synagogue total revenue for the most recently completed Fiscal Year *
Dues revenue
Synagogue total operating expenses for the most recently completed Fiscal Year *
Did your synagogue receive a PPP loan?

Yes No
Do you have a pre-school?

Yes No
We certify that the figures and statements shown on this page are true and accurate. (ALL signatures required)
Select Signee: *

President Executive Director Treasurer
Signature: *

Please use your mouse or finger to sign. Clear
Print name: *
Phone Number: *

Area Code Phone Number
Email: *
example@example.com
Thank you for your partnership with USCJ!

United Synagogue of Conservative Judaism (USCJ) 3080 Broadway, Suite B208, New York, NY 10027 Phone: (646) 519-9261 Email: dues@uscj.org Website: www.uscj.org
Should be Empty:

Membership Reporting Form 2020-21

Part One: Membership Information

Dues Calculation:

Part Two: Dues Payment Plan Options

Thank you for your partnership with USCJ!