Dues Adjustment Form - Anshe Sholom B'nai Israel Congregation

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DUES ADJUSTMENT FORM

ASBI is committed to making accommodations that respect the financial capacity of our individuals and families. No one will be denied membership due to financial circumstances. Dues Adjustments happen on an annual basis; even if you have been granted an adjustment in previous years, you must submit a new request for the current year (beginning July 1, 2022 and ending June 30, 2023).

All forms will be reviewed by a 3-person “Dues Adjustment Committee.” This is a confidential process - names are removed before forms are reviewed by the committee. A response to your request will be sent via email; it may take 1-3 weeks. Once your dues amount is finalized, you will be expected to immediately make your payment or set up your payment plan.

* First Name:

* Last Name:

* Email Address:

* Please enter in the adjusted total amount you would like to pay in membership dues for the 2022-2023 year:

To be paid by:

To be paid in the following number of payments

Payment Plan Start Date (all payments must be completed prior to June 30, 2023)

Payment frequency:

* (REQUIRED) Please explain why you need this adjustment:

* I understand that I will not be in good standing until I have made a payment or set up a payment plan upon approval of my Dues Adjustment Request. I understand that these arrangements are for the 2022-2023 membership year only.

I understand that I will not be in good standing until I have made a payment or set up a payment plan upon approval of my Dues Adjustment Request. I understand that these arrangements are for the 2022-2023 membership year only.

After you click "Submit" please check your email for a confirmation to ensure that your form has been received.

Wed, March 22 2023 29 Adar 5783