Ten Yad - Chabad of NW Bergen County

MISSION STATEMENT

To provide emergency financial assistance to women and children in the Franklin Lakes (& Chabad service area) Jewish community struggling with poverty or abuse & preserve dignity in accordance with the Jewish value of Tzedakah.

FINANCIAL ASSISTANCE
- Clothing - Including work and school uniforms
- Food - Emergency and supplemental food
- Medical - Emergency medical situations, prescriptions, and co-payments
- Professional Services - Assistance for social services, legal aid, guidance counselors, etc., to promote self-sufficiency, independence and, employment
- Shelter - Short-term lodging or rent if faced with imminent eviction
- Utilities - To prevent disconnection of electric, heat, water and cell-phone.
- Transportation - Emergency vehicle repairs and work transportation
- Tuition - Subsidized tuition for children’s day-camp and education
PROCESS

After an initial interview, applicants must complete a discreet intake procedure and satisfy eligibility requirements including providing basic financial details, references, and support from a religious or communal figure familiar with the individual.

If approved, Ten Yad can offer financial assistance up to $5,000 per year in the form of cash, direct bill payment or vouchers at the discretion of the administrator.
**Do NOT complete this form until AFTER a pre-application interview is completed.**
APPLICATION
This is a secure and discreet form which will ONLY be viewed by the executive administration of Ten Yad.
1. Personal Information
Full Name*
First Name Last Name
E-mail*
Phone Number*

Area Code Phone Number

Current Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date of Birth*

Month Day Year
2. Family Info
Marital Status*
Residence Status*
Number of Children*
Child #1 - Age
Living arrangements
Child #2 - Age
Living arrangements
Child #3 - Age
Living arrangements
3. Assistance Description
Hardship Description* Please briefly describe your background and the current difficulty you are facing
Assistance Purpose* Please briefly describe what you will use the funds for if approved for financial assitance.
Other Assistance* List any other organizations you are currently receiving services or support from.
4. References
Please provide two personal references and one communal/professional reference (i.e. Rabbi, Social Worker, etc,)
Personal Reference 1*
First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
Personal Reference 2*
First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
Professional Reference*
First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
5. Employment & Income
Current Employment*

Full-timePart-timeUnemployed
Describe the nature of your employment
Annual Employment Income $* For the previous fiscal year
Other Income Sources $* For the previous fiscal year
Employer Name
Employer Phone

Area Code Phone Number
6. Agreement
Please Check ALL* We will NOT contact your references or employer if we are familiar with your situation.

I confirm that all information provided is true and accurate.I give permission for my employer to be contacted.I give permission for my references to be contacted.I give permission for my application to be reviewed by Ten Yad advisors.If approved, I will write an (anonymous) thank you letter to Ten Yad's donors.
Should be Empty:

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APPLICATION

1. Personal Information

2. Family Info

3. Assistance Description

4. References

5. Employment & Income

6. Agreement