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Fee Adjustment Request Form


Please list family/dependents and ages.


Please complete this application.
You may be asked to submit copies of your Federal Income Tax Form to:
Temple Israel of Albany
Special Considerations Committee
600 New Scotland Avenue, Albany, NY, 12208

The final determination for adjustment will be made by the Special Considerations Committee after review of the information provided by you including your most recent Federal Tax Return.
Please see individual program registration forms for cost.
Please email the registration form to tidirector@tialbany.org.

Income Source
(i.e. Employer, SSI, Disability, Alimony, Child Support)(i.e. Employer, SSI, Disability, Alimony, Child Support)
(i.e. Employer, SSI, Disability, Alimony, Child Support)(i.e. Employer, SSI, Disability, Alimony, Child Support)
(i.e. Employer, SSI, Disability, Alimony, Child Support)(i.e. Employer, SSI, Disability, Alimony, Child Support)
(i.e. Employer, SSI, Disability, Alimony, Child Support)(i.e. Employer, SSI, Disability, Alimony, Child Support)
(i.e. Employer, SSI, Disability, Alimony, Child Support)(i.e. Employer, SSI, Disability, Alimony, Child Support)

EXPENSES
Mortgage/Rent Payment -
please specify if it is per month or per year
Health Insurance - 
​​​​​​​please specify if it is per month or per year.
Car Insurance - 
​​​​​​​please specify if it is per month or per year.
Utilities (electric, heat, hot water, telephone)
Utilities - 
please specify if it is per month or per year.
Car Payments -  
please specify if it is per month or per year.
Child Care - 
please specify if it is per month or per year.
School Tuition - 
please specify if it is per month or per year.
please specify if it is per month or per year.
please specify if it is per month or per year.

Mon, August 15 2022 18 Av 5782