The Blue Card - 2024 Holocaust Survivor Referral Form

Referring Clients to The Blue Card

The Blue Card’s mission is to provide financial assistance to needy Holocaust survivors. The Blue Card is an agency of last resort and fills a need in areas unmet by other agencies and public programs. Grant amounts depend upon financial need, as well as upon resources.

The Blue Card is a financial aid organization, not a social service agency. Potential clients must be referred by a social worker that first performs a financial assessment and helps the client access all entitlements. The client should also be guided in applying for government assistance by their social worker.

Please inform your clients that we do not work directly with survivors. All questions and concerns should be brought to the referring social worker.

Referral on your agency’s letterhead should include:

A brief Holocaust history for the client covering the years 1933-1945 with dates and places
Your recommendation for The Blue Card services for the client, why you believe the service is necessary for that particular person, and any relevant medical or financial history regarding the client's need for assistance
Statement as to why the client is not eligible for government or agency assistance, if applicable
Please explain how your agency is assisting the survivor
Our questionnaire does not replace your narrative and referral

The Blue Card provides several forms of financial aid:

Claims Conference Emergency Assistance Program (medical, dental, minor home modification, and burial needs)
The Blue Card funded programs (holiday, birthday, Telephone Emergency Response System, monthly stipend, battery operated companion pet, mood light box, Cost Plus Drug Company Partnership)
Please reach out to us to inquire about your area's eligibility before applying for the above programs

Please enclose the following current proofs of income and expenses:

Photo ID
Award letter from SSI, SSA, SSD
Lease/Rental agreement, Rent Increase Exemption Letter (SCRIE), (if applicable)
SNAP award letter (if not receiving, please provide current asset information)
Last month’s bank statement showing expenses listed on the financial form
Supporting documentation for the request from the vendor if applicable

Applicant Full Name*

First NameLast Name

Previous Name/Maiden Name*

Last Four Digits of Social Security Number*

Phone Number of Applicant*

Area CodePhone Number

Date of Birth*

DayMonthYear

City, Country of Birth*

Marital Status*

SingleMarriedDivorcedWidowed

Spouse's Full Name

Spouse First NameSpouse Last Name

Is the Spouse a Survivor?

YesNo

Last Four Digits of Social Security Number

Spouse's Date of Birth

DayMonthYear

Spouse City, Country of Birth

Date of Divorce

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Blue Card Program Recommendation

Emergency Assistance Programs Recommendation

Financial Aid Recommendation Not Listed Above

Monthly SSA/SSI/SSD*

Pension from other countries*

Nazi Restitution/ Claims Conference*

Other Pensions/IRA*

Other Salary and/or Income, including funds from agency and family*

SNAP Benefits*

Please select all that apply*

Total of all bank accounts and investments*

Health Insurance/Life Insurance*

Specify per month or year

Gas/Electric/Phone/ Cable*

Specify per month or year

Medical/R:*

Specify per month or year

Food:*

Specify per month or year

Monthly Payments (Debt)*

Specify per month or year

Rent/Mortgage (after Sect 8 or SCRIE)*

Per month

Other (Please Explain)*

Specify per month or year

Did you file taxes?*

YesNoOther

Case Worker Recommendation and Holocaust History:*

Additionally, kindly include the following supporting documentation:

legible Photo ID
Award letter from SSI, SSA, SSD
Lease/Rental agreement, Rent Increase Exemption Letter (SCRIE), (if applicable)
SNAP award letter (if not receiving, please provide current asset information)
Last month’s bank statement showing expenses listed on the financial form
Supporting documentation for the request from the vendor if applicable
For Dental - 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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Upload Authorization to Release/Obtain Information Form:*

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Upload Consent Form:*

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Upload Declaration of Income and Assets Form*

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Upload Interagency Consent Form:*

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

Case Worker Signature:*

Case Worker Email Address:*

Case Worker Telephone Number:*

Date*

DayMonthYear

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

YESNO

Is the applicant interested in being connected with a volunteer via the phone or in person? This volunteer would provide emotional support and companionship.

Yes, via telephoneYes, in personYes, in person and they do not speak EnglishYes, via telephone and they do not speak English

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The Blue Card - 2024 Holocaust Survivor Referral Form

General Information

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

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