Fee Adjustment Request Form - Form - Temple Israel of Albany

* Applicant Family Name

* Email

* Marital Status

* Home Address

* City

* State

* Zip

Mailing Address is Different:

* Phone (C):

Phone (W):

Phone (H):

* ***Are You a Member of Temple Israel of Albany?

Please list if you are affiliated anywhere

Household Members

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 let us know what you are applying for:

* Full Amount

* Other Assistance Granted

* Source of Other Assistance

* Amount Requested for Special Consideration

Do you wish to apply for fee adjustment for another program?

How many weeks are you hoping to enroll your child/ren?

* Full Amount

* Other Assistance Granted

* Source of Other Assistance

* Amount Requested for Special Consideration

* Full Amount

* Other Assistance Granted

* Source of Other Assistance

* Amount Requested for Special Consideration

Please see individual program registration forms for cost.
Please email the registration form to tidirector@tialbany.org.

Income Source

* How Many Sources of Income are there?

* Name

* Type of Source