Dues Pledge — Hevrat Shalom Congregation

You may also print this form and mail it to Hevrat Shalom Congregation, P.O. Box 3606, Gaithersburg, MD 20878.

Contact Information

First Name *

Last Name *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Dues Pledge Schedule

Please select your family circumstances to establish your minimum dues, then enter any additional amount you're able to pledge. Most members generously pledge more than the minimum, according to their financial ability — Hevrat Shalom will never turn away a member because of inability to pay. If you're facing a special situation or financial hardship, please request a confidential meeting.

Family $825 Single $600 Ingleside Family $745 Ingleside Single $540

The above are the minimum dues requested — please pledge more if you can. Dues include High Holiday tickets. Dues for new members are half price for the first year of membership.

Additional Dues

Oneg & Special Events

Please indicate below a special event or memory for which you wish your sponsored Oneg to be acknowledged.

Amount Pledged

Event

Date

Additional Gifts & Contributions

For special occasions such as birthdays and Yahrzeits, to be acknowledged from the Bimah and in our newsletter.

Amount Pledged

Purpose

Special Assessment

In addition to the membership pledge, there is a mandatory special assessment of $100 per membership.

Amount — Special Assessment *

Payment & Directory Listing

I/we pledge the above total amount for membership dues and assessment for the fiscal year beginning July 3rd.

Total Amount Pledged $0.00

Payment Schedule *

Annually Semi-Annually Quarterly

Include in Annual Membership Directory? *

Yes No

Signature

Electronic Signature *

Today's Date *