• The Blue Card - 2023 Holocaust Survivor Referral Form

    The Blue Card - 2023 Holocaust Survivor Referral Form

  • General Information

    Please fill out this section completely.
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  • 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

    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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