Etty Spitzer

Dedicated Job Title with excellent experience in industry. Maintains professional appearance and demeanor and expertly completes assigned tasks with focus on quality. Dependable and quick-learning team player with effective communication and organization skills.

• NO ‐ Please mail me a replacement card
• If any of the following information is incorrect or has changed, please cross out and update
• Address: 2370 Forest Circle Toms River, New Jersey 08755 Phone number: 732‐905‐0241 Cell phone number‐ 3473871633‐ OK Txt, No VM
• Email Address‐ ettyspitzer@gmail.com Family size‐ 2 Parents and 3 Single children
• (Single children includes any children who you are financially responsible to feed and clothe.) Family Rav: R' Schener 7184191005 Other Forms of Assistance
• Food Stamps: Receives Food Stamps Tomchei Shabbos: Tomchei Shabbos‐ Monthly Other community assistance:
• Do you receive any other assistance not listed above
• Please indicate if there are any extenuating circumstances at this time, please give as much information as you are comfortable giving as this will help us best determine your family’s needs
• Are there any family members with high out of pocket medical bills or is there an inability to provide adequate income due to a medical reason
• (If more than one family member has medical expenses, please indicate how many family members have medical expenses
• If possible, please explain)
• Husbands’ occupation__________________________________ Wife’s occupation_____________________________ Combined ANNUAL income: $0 The income listed is correct Incorrect income‐ our income is $ _________________
• SIGNATURES‐ without requested signatures this form is invalid:
• I, _______________________ certify that all the information on this form is true and correct and that I am in need of financial assistance from Ahavas Tzedakah
• In addition I understand the importance of reading the instructions that come with the shopping/activation mailing and will read through it thoroughly before activating my card
• Signature: _____________________________ Date: ___________________
• I DO NOT currently have $50,000 or above
• In savings
• Signature: ___________________ Date: ___________________ I DO currently have savings greater than $50,000
• My total amount in savings is around $____________________ Please indicate on the back of this form if there is something specific this is being saved for and if you have access to this money
• (Please provide this information regardless of if you have indicated previously.)