Skip to content

Chasdei Efrat

Aid Request Form

Home>
Aid Request Form

For financial assistance, please fill out this form in its entirety.

If you have questions or encounter any difficulties, write to info@chasdeiefrat.org
Thank you.

PLEASE NOTE:

When filling out this form, you will be required to upload

a copy of your teudat zehut
bank statements / ishur Bituah Leumi / pay stubs – for last three months

We recommend you prepare those documents before you start to fill out the form as the form will not be completed without uploading the documents.

When form is completed – you will see a message that form was successfully completed – and you will receive a copy of the form to your email.

"*" indicates required fields

Step 1 of 4

25%

What kind of assistance do you need?*

Holiday Help

Other Assistance

Last name*

First name*

Teudat Zehut/ID Card Number*

Please upload a photo of your Teudat Zehut (ID Card) and the Sefach (Appendix)*

Drop files here or

Max. file size: 256 MB.

Date of birth*

Address*

Phone number*

Additional phone number

Email*

Gender*

Male

Female

Place of employment*

Job Description

Marital status*

Married

Single

Divorced

Widowed

Separated

Spouse

Last name*

First name*

Teudat Zehut/ID Card Number*

Please upload a photo of your Teudat Zehut (ID Card) and the Sefach (Appendix)*

Drop files here or

Max. file size: 256 MB.

Date of birth*

Day

Month

Year

Address*

Phone number*

Additional Phone number

Email*

Place of employment*

Job Description

Additional Household Members

Name

Year of birth

T.Z. number

Occupation

Monthly Income

Lives at home

Monthly Income for Household (in NIS)

Workplace net income*

Bituah Leumi (child allowance, disability payments)*

Child Support (Mezonot)*

Monthly help from family or friends*

Other income (rental, pensions, investments)*

Monthly income from abroad*

Your monthly income (in NIS)

Workplace net income*

Bituah Leumi (child allowance, disability payments)*

Child Support (Mezonot)*

Monthly help from family or friends*

Monthly income from abroad*

Other income (rental, pensions, investments)*

Spouse's monthly income (in NIS)

Workplace net income*

Bituah Leumi (child allowance, disability payments)*

Mezonot (child support)*

Monthly help from family or friends*

Monthly income from abroad*

Other income (rental, pensions, investments)*

Estimated monthly expenses (in NIS)

Rent*

Education*

Car expenses (gas, insurance, upkeep)*

Mortgage*

Chugim*

Clothing*

Insurance*

Medical*

Arnona / Water / Security*

Groceries*

Electricity*

Maintenance*

Other

Upload Files*

Please submit pay stubs, credit card statements and bank statements from the last 3 months. If you receive assistance from Bituach Leumi (National Insurance), add the last 3 statements from them too.

Drop files here or

Max. file size: 256 MB.

Discounts

Do you receive an Arnona discount?

Yes

No

How much is your Arnona bill after the discount?*

What percentage is the discount?

Do you receive a tuition discount?*

Yes

No

How much is your tuition after the discount?*

What percentage is the discount?

Please list assets owned in Israel and abroad (real estate, bank accounts, etc.).

House/Apartment*

Car/s*

Other/s*

Do you have any outstanding loans? If yes, please specify.

Do you have any outstanding bank loans?*

Yes

No

Total loan*

Left to reimburse*

Do you have any outstanding credit card loans?*

Yes

No

Total loan*

Left to reimburse*

Do you have any outstanding family loans?*

Yes

No

Total loan*

Left to reimburse*

Do you have any other outstanding loans?*

Yes

No

Total loan*

Left to reimburse*

Do you have any outstanding bills (e.g., credit card debt, arnona, electricity, dental or medical, home repair)?*

Yes

No

Outstanding Bills*

Bill

Amount in NIS

Do you have any outstanding debts?*

Yes

No

Outstanding Bills*

Debt

Amount in NIS

Do you have a file with the Social Services Department?*

Yes

No

Hidden

Name of assigned Social Worker*

Please sign a Waiver of Confidentiality so we can work together with the Social Services Department

I hereby authorize the Director of the social services department, or anyone empowered by him, to receive from or share information about myself or any of my family members, with the Chasdei Efrat fund, and I waive all obligations of confidentiality from him.

Name*

Teudat Zehut/ID Card Number*

Signature*

What is the reason you are turning to us for help specifically at this time?*

(Please attach any supporting documents that might be relevant, such as medical opinions or legal bills)

File

Please attach any supporting documents that might be relevant

Drop files here or

Max. file size: 256 MB.

What kind of help are you asking for?*

Please select from options below

Loan

Scholarship

Grant

Weekly Food Basket

Financial Guidance

Other

What kind of help are you asking for?*

Are you receiving help from any other sources?*

Yes

No

Please specify*

Have you received financial guidance from a service such as Mekimi or Pa'amonim?*

Yes

No

Hidden

Name of assigned Counselor

Phone

Please sign a Waiver of Confidentiality so we can work together with the above counselor.

I hereby authorize the Financial Counselor named above, or anyone empowered by him, to receive from or share information about myself or any of my family members, with the Chasdei Efrat Fund, and I waive all obligations of confidentiality from him.

Name*

Teudat Zehut Number*

Signature*

Hidden

Consent*

I /hereby declare, that all the information above is accurate.

Signature of Applicant*

Signature of Spouse*

Date*

DD slash MM slash YYYY

CAPTCHA

Copyright - OceanWP Theme by OceanWP