The Blue Card - 2021 Holocaust Survivor Referral Form

The Blue Card - 2021 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
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
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
Financial Aid Recommendation:

In the space below, kindly provide your recommendation on ways you believe The Blue Card can best serve your client.
Case Worker Recommendation:
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).
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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Cancel of
Consent Form:

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

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Cancel of
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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Cancel of
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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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
Holocaust Survivor Verbal Consent *
Verbal Consent signatures (if applicable)

I confirm that onDate at Time, I received verbal acceptance of all of the conditions and terms as outlined in the below indicated forms from the client listed above.

Authorization to Release/Obtain Information
Consent Form
Jewish Nazi Victim Eligibility Assessment
Income and Asset Declaration Form

First Name Last Name Title
Signature Date
Is the applicant interested in participating in speaking engagements about their experience? *

YES NO
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The Blue Card - 2021 Holocaust Survivor Referral Form

General Information

General Financial Information

General Financial Information

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:

Signatures