The Blue Card - 2023 Holocaust Survivor Referral Form

The Blue Card - 2023 Holocaust Survivor Referral Form
General Information

Please fill out this section completely.
Applicant Full Name*

First NameLast Name
Previous Name/Maiden Name*
Last Four Digits of Social Security Number*
Date of Birth*

DayMonthYear
City, Country of Birth*
Marital Status*

SingleMarriedDivorcedWidowed
Spouse's Full Name

Spouse First NameSpouse Last Name
Is the Spouse a Survivor?

YesNo
Last Four Digits of Social Security Number
Spouse's Date of Birth

DayMonthYear
Spouse City, Country of Birth
Date of Divorce

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please choose one or more financial aid recommendations from the two questions below. If you do not see the financial aid recommendation the survivor needs listed, please detail the request in the box.
Blue Card Program Recommendation

Telephone Emergency ResponseHolidayMazel Tov BirthdayMonthly StipendSiggi B. Wilzig Fighting Cancer Together ProgramMark Cuban's Cost Plus Drugs ProgramFreestyle Libre 2Robotic Companion Pet
Emergency Assistance Programs Recommendation

DentalHearing AidesRental assistanceFood assistanceUtilities assistanceTransportationHome modification (railings, stair lift, home damage, appliance repair)Winter coatMedication or medical expense
Financial Aid Recommendation Not Listed Above
General Financial Information

Please Include All Monthly Household Income
Monthly SSA/SSI/SSD*
Pension from other countries*
Nazi Restitution/ Claims Conference*
Other Pensions/IRA*
Other Income, including funds from agency and family*
SNAP Benefits*
Please select all that apply*

MedicarePart DMedicaidEpicOtherNone
Total of all bank accounts and investments*
General Financial Information

Please Include All Monthly Household Expenses
Health Insurance/Life Insurance*
Gas/Electric/Phone/ Cable*
Medical/R:*
Foo:*
Monthly Payments (Debt)*
Rent/Mortgage (after Sect 8 or SCRIE)*
Other (Please Explain)*
Did you file taxes?*

YesNo
Holocaust History and Financial Aid Recommendation:

In the space below, kindly provide client's brief Holocaust history and your recommendation on ways you believe The Blue Card can best serve your client.
Case Worker Recommendation and Holocaust History:*
Conditions Upon Acceptance
Additionally, kindly include the following supporting documentation:
- Confirmation that the client is approved for Claims Conference Social Welfare funded programs (i.e Hardship Fund, Article 2, BEG, Slave Labor Fund).
- Government issued photo ID (A clear photocopy or a clear photograph).
- Most current award letter from SSI, SSA, SSD and SNAP Benefits.
- Official lease/rental agreement, Senior Citizen Rent Increase Exemption Letter (SCRIE), (if applicable).
- If not receiving government benefits (SNAP/SSI/Medicaid), please provide current asset information.
- Most recent bank statements.
- Vendor invoice in support of request. For dental requests, please include a proposed treatment plan and x-rays (either digital or hardcopy).
*Please note that additional information/documentation may be requested during the application process.
Upload supporting documentation:*

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ADDITIONAL REQUIRED FORMS

Please complete and upload the following forms:
Authorization to Release/Obtain Information:

Please download the form, fill it out, and upload to submit with application.
*
Upload Authorization to Release/Obtain Information Form:*

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Consent Form:

Please download the form, fill it out, and upload to submit with application.
Upload Consent Form:*

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Nazi Victim Eligibility Assessment Form:

Please download the form, fill it out, and upload to submit with application.
Upload Nazi Victim Eligibility Assessment Form*

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Declaration of Income and Assets Form:

Please download the form, fill it out, and upload to submit with application.
Upload Declaration of Income and Assets Form*

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Interagency Consent Form:

Please download the form, fill it out, and upload to submit with application.
Upload Interagency Consent Form:*

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Signatures
I affirm that the information in this for is true and accurate according to my knowledge.
Case Worker Signature:*

Clear
Case Worker Email Address:*
Case Worker Telephone Number:*
Date*

DayMonthYear
Is the applicant interested in participating in speaking engagements about their experience?*

YESNO
Is the applicant interested in being connected with a volunteer via the phone or in person? This volunteer would provide emotional support and companionship.

Yes, via telephoneYes, in personYes, in person and they do not speak EnglishYes, via telephone and they do not speak English
Should be Empty:

The Blue Card - 2023 Holocaust Survivor Referral Form

General Information

Please choose one or more financial aid recommendations from the two questions below. If you do not see the financial aid recommendation the survivor needs listed, please detail the request in the box.

General Financial Information

General Financial Information

Holocaust History and Financial Aid Recommendation:

Conditions Upon Acceptance

ADDITIONAL REQUIRED FORMS

Authorization to Release/Obtain Information:

Consent Form:

Nazi Victim Eligibility Assessment Form:

Declaration of Income and Assets Form:

Interagency Consent Form:

Signatures