Jewish Long Beach Fee Adjustment and Financial Aid Application

Jewish Long Beach Fee Adjustment and Financial Aid Application
Shalom,

Thank you for being a member of the Alpert Jewish Community Center. It is our mission to provide programs and services that contribute to the sound development of individuals of all ages and to offer opportunities to enhance appreciation of Jewish and democratic values in Long Beach and West Orange County. Fee adjustments & financial aid are determined annually and are not automatically renewed. We require members to renew their applications each year for us to evaluate and accommodate changing personal circumstances. We understand our members’ lives change from year to year, and that while some may no longer need assistance, others may need to apply for additional support. This yearly renewal allows us to reconnect with our members to serve them to the best of our ability.

The application will take about 5 - 10 minutes to complete. You will need to provide the following information:
- Employer contact information for you and your spouse/partner (if applicable)
- Values of family assets & liabilities (equities, investments, savings, loans)
- Gross earnings (income, salaries, child support, alimony, etc) and payments (rent, mortgage, loans, medical, etc)
- Most recent federal tax return (via file upload)
- TWO recent pay stubs (via file upload)
Your application will not be processed without the following:
- Completed Application. All questions on the Financial Aid/Fee Adjustment Application must be answered; those that are not applicable must be answered with N/A.
- Most recent copy of your completed Individual Federal Tax Return. If you are self-employed, please include business tax returns.
- Copies of your two most recent pay stubs and verification of any other income.
For membership fee adjustment applicants: Please note that you MUST complete a membership application by downloading it from our website, in person, or by emailing msears@alpertjcc.org
Select one*

New applicationRenewal

Member Information
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Occupation*
Employer*
Employer phone*
Please enter a valid phone number.
Employer address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*

MarriedDivorcedSeparatedWidowedSingle
Spouse/partner name

First NameLast Name
Spouse/partner occupation
Spouse/partner employer
Spouse/partner employer phone
Please enter a valid phone number.
Spouse/partner employer address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have dependent children?*

YesNo

Dependent Children

Please list all
Child #1

First NameLast Name
Child #1 DOB

MonthDayYear
Date
Child #1 Grade/program
Child #2

First NameLast Name
Child #2 DOB

MonthDayYear
Date
Child #2 Grade/program
Child #3

First NameLast Name
Child #3 DOB

MonthDayYear
Date
Child #3 Grade/program
Names of others living at home
Provide name and relation

Assets & Liabilities

Please list the values of the following family assets and liabilities
Home
Equities in other real property
Cash in bank
Savings and certificates of deposit
Investment securities
Trust funds
Automobiles (make & year)
Investment in business & partnerships
Other assets
Bank loans
Other loans
Other liabilities
Earnings

Please indicate the amount of gross earnings you anticipate receiving during the current year
Salaries and/or business income of all adults
Contributions from or expenses paid by other individuals
Rental income
Child support
Alimony
Payments

Please give amounts of payments anticipated during the current year for the following
Rent or mortgage payments
Synagogue dues or other religious affiliations
Installment loans or leases
Unusual medical expenses

Additional Information
Does anyone in your family or household identify as Jewish?
We collect this information to better understand the community we serve - your response is optional
Synagogue Member

YesNo
Congregation
Have you received an adjusted fee for any Jewish Long Beach program or AJCC membership in the last year?*

YesNo
Please indicate amount received
Please describe your reason for needing a fee adjustment*
You may attach a separate page if necessary
Separate page if necessary

Cancelof
Most recent individual Federal Tax Return*

Cancelof
TWO most recent pay stubs*

Cancelof
Other income verification

Cancelof
Terms

I declare that the information contained in this form, to the best of my knowledge and belief, is true, correct, and complete. If I receive a fee adjustment, I agree to pay the remaining sums due in a timely manner. I understand that a fee adjustment is not automatically renewable and must be reviewed annually.
I, the undersigned, agree to the terms above*

Clear
Today's Date*

MonthDayYear
Date
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Jewish Long Beach Fee Adjustment and Financial Aid Application

Member Information

Dependent Children

Assets & Liabilities

Earnings

Payments

Programs and services

Additional Information