Membership Reporting Form 2022-23
Date
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Month
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Day
Year
Date
Synagogue Name
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City
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State/Province
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Part One: Membership Information
Number of member units paying $500 or more in membership dues
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Number of member units paying between $191 and $499 in membership dues
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Number of member units paying under $191 in membership dues
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Total Number of membership units
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Dues Calculation:
Member units paying $500 or more (USCJ dues $74.50/unit) Line 2 above X $74.50 =
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Member units paying $191-$499 (USCJ dues $37.25/unit) Line 3 above X $37.25 =
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Member units paying under $191 (USCJ dues $0.00/unit) Line 4 above X $0.00 =
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Total Dues (Calculated)
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Sum of 3 lines above.
Part Two: Dues Payment Plan Options
Please check one option below:
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Paid in full by December 31, 2022.
Paid in full by December 31, 2022 and we will also submit our membership mailing/email list by years end to receive the early dues 2.5% payment discount.
Quarterly payments – to be received by 15th of the months August, October, January and April.
Ten (10) equal payments – initial payment in July 2022 and final payment in April 2023.
Twelve (12) equal payments – July 2022 to June 2023.
How would you like to pay:
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Mail a check to USCJ (see address below)
Automatic payment plan (ACH or wire transfer) - we will contact you to give you more information including setting this up online
Credit card payment which can be made online or please contact us to give us your information
We certify that the figures and statements shown on this page are true and accurate. Only one signature required.
Select Signee:
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President
Executive Director
Treasurer
Signature:
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Please use your mouse or finger to sign.
Clear
Print name:
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Phone Number:
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Area Code
Phone Number
Email:
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example@example.com
Thank you for your partnership with USCJ!
United Synagogue of Conservative Judaism (USCJ) 3080 Broadway, Suite B208, New York, NY 10027
If you have questions or concerns, please contact:
Roumi Kovachev: dues@uscj.org/646-519-9261 Barry Mael: mael@uscj.org/732-738-4302
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