• The Blue Card - 2022 Holocaust Survivor Referral Form

  • General Information

    Please fill out this section completely.
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  • General Financial Information

    Please Include All Monthly Household Income
  • General Financial Information

    Please Include All Monthly Household Expenses

  • 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.
  • 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.

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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.
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  • Consent Form:

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

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

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

    Please download the form, fill it out, and upload to submit with application.
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  • Signatures

  • I affirm that the information in this for is true and accurate according to my knowledge.

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