The Blue Card - 2022 Holocaust Survivor Referral Form

The Blue Card - 2022 Holocaust Survivor Referral Form
General Information

Please fill out this section completely.
Applicant Full Name *

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

Day Month Year
City, Country of Birth *
Marital Status *

Single Married Divorced Widowed
Spouse's Full Name

Spouse First Name Spouse Last Name
Is the Spouse a Survivor?

Yes No
Last Four Digits of Social Security Number
Spouse's Date of Birth

Day Month Year
Spouse City, Country of Birth
Date of Divorce

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Financial Aid Recommendation *
General Financial Information

Please Include All Monthly Household Income
Monthly SSA/SSI/SSD: *
Pension from other countries: *
Other Pensions/IRA: *
Other Income: *
SNAP Benefits: *
Please select all that apply: *

Medicare Part D Medicaid Epic Other None
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/RX: *
Food: *
Monthly Payments (Debt): *
Rent/Mortgage (after Sect 8 or SCRIE): *
Other (Please Explain): *
Did you file taxes? *

Yes No
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 *

Day Month Year
Is the applicant interested in participating in speaking engagements about their experience? *

YES NO
Should be Empty:

The Blue Card - 2022 Holocaust Survivor Referral Form

General Information

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