Membership/Dues Form

Congregation Beth Shalom 2016-17 Membership Form      PAGE 1 OF 2
(Please return this form with your dues pledge and first payment by October 1, 2016) 

With this household income, please pay this annual tax-deductible amount.

Under $25,000.  __ Please pay $275.00
1 payment of $275; 2 payments of $142 each
$25,000 – $35,000. __ Please pay $440.00
1 payment of $440;  2 payments of $225; 3 payments of $150
$35,000 – $50,000. __ Please pay $585.00
1 payment of $585;  2 payments of $295; 3 payments of $200
$50,000 – $75,000. __ Please pay $720.00
1 payment of $720;  2 payments of $365; 3 payments of $245
$75,000 – $100,000. __ Please pay $ 900.00
1 p
ayment of $900; 2 payments of $455; 3 payments of $305
$100,000 – $125,000. __ Please pay $1,150.00
1 payment of $1,150; 2 payments of $580; 3 payments of $390
Over $125,000. __ Please pay $1,400.00
1 payment of $1,400; 2 payments of $705; 3 payments of $470

__ 1-payment plan due by October 1
__ 2-payment plan due by October 1 and December 1
__ 3-payment plan due by October 1, December 1, and February 1
Please note that an additional charge is required for two and three payments.

NO ONE WILL BE DENIED MEMBERSHIP FOR FINANCIAL REASONS
For special financial arrangements, please contact Jeff Hecht. All information is maintained in strict confidence.

Please fill out the other page of this form completely.

 

[should print on two pages]

 

 

 

Congregation Beth Shalom 2016-17 Membership Form PAGE 2 OF 2
This part of the form is used for haShofar mailings and other important communications.

Name ______________________________________________________

□ If there are no changes from last year to your address, phone, or e-mail, check this box and omit the information below.

Address _______________________________________________________________________________

Home phone __________________ Cell phone _________________ (name:_____________)

E-mail _________________________ (name) E-mail__________________________(name)

Please rank your preferred phone contact: ___Home phone ___ Cell phone ___ E-mail

—————————————————————————————————————————–

2016-2017 Additional Pledge (additional tax-deductible donations)
Please indicate amount for any additional pledge:
Unrestricted ________ (Congregation operating expenses)
Raymond Katz Building Fund __________ (Building maintenance and repair)
Rabbi Fund _________ (Current and future Rabbi salary)
Rabbi Discretionary Fund _______ (Spent for religious and educational purposes)
Fox/Mabel Fund ______  (For educational projects including the religious school, library, and other educational opportunities)
Religious School ______ (not school fees; Religious School donations)
Community Fund ________ (Hope Haven, Members in need, Community needs)
DeKalb Food Pantry ______ (Food for the needy in DeKalb County)
Cemetery Fund ______  (Repair and maintenance of Garden of Shalom Cemetery)
Other purpose _______  (Please specify purpose) ________________________________

To pay by check, enclose check with this form or mail separately to address below.
To pay by credit card, go to our website, http://bethshalomdekalb.org  (5 percent credit card fee).

Total 2016-2017 Pledge [dues (from other page) + additional pledges] = $______

SEND PAYMENTS  AND ANY CORRESPONDENCE TO:
Congregation Beth Shalom. PO Box 1177, DeKalb, IL 60115

The IRS requires that tax-exempt organizations return a receipt to the donor for dues and donations so that the donor may utilize the tax deduction. A tax letter will be sent by Jan. 31.

Thank you for helping the Congregation to meet its financial obligations.

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