2010 West Koch St. Bozeman, MT 59718-4069 | (406) 556-0528 | administrator@bethshalombozeman.net | www.bethshalombozeman.org

Affiliation Information (July 1, 2017-June 30, 2018) Return by July 31, 2017

All information on this form is held in confidence. No one will be denied affiliation because of an inability to pay. Please complete all of the form. We need this information in order to plan for your needs. If you have any questions, please call our Administrator, Lisa Roots, 406 556 0528 Name: _______________________________ Spouse or partner’s name:_________________________________ Please select a level below for supporting Congregation Beth Shalom in a manner that best matches your ability, remembering that a stretch is a mitzvah, Contributions are generally fully tax deductible, but please consult your tax adviser. Our Tax ID # is: 81-04888804.

RECOMMENDED contribution levels

Annual Monthly* (based on 12 automatic bank draft payments 7/15/17 – 6/15/18) Family $1080 $90 $ Individual $680 $56.67 $ Under 30 $18 N/A $ Student $18 N/A $ Associate $680 $56.67 $ Affiliate $680 $56.67 $______________ Friend $______________

Hebrew School See the calendar on our website for classes. Recommended fees include $30 materials fee. Annual Monthly* Shalom Tots (ages 3-5) $370 $30.83 $ Shalom Tweens (ages 6-9) $400 $33.33 $ Shalom Kids (ages 10-12) $400 $33.33 $_____________

PLEASE CONSIDER AN ENHANCED CONTRIBUTION BY JOINING OUR SHOMRIM

(GUARDIAN) SOCIETY

Torah Circle $10,000 or more $ Tsedaka (Justice) Circle $7,500-9,999 $ Chai (Life) Circle $5,000-7,499 $ Bonim (Builders) Circle $2,500-4,999 $ Mitzvah Circle $1000-2,499 $ Please check here if you wish your contribution to remain anonymous.

Building Fund Contribution We request that each member pledge $2,000 over a period of five years toward the upkeep and related expenses of the building. Please elect a payment option and include your current payment with your membership contribution. I am a new member and wish to contribute $2000. I am a new member and am pledging $400 per year for the next 5 years

Endowment Some members may also wish to make a financial endowment. Your contribution would be preserved for a stated period or in perpetuity, with interest paid to the Temple. If you wish to make an endowment payment, please contact the Temple President.

AFFILIATION CATEGORIES

Family: Open to any family unit that includes a Jewish person. Single: Open to any Jewish person who resides alone (no partner or minor children). Under 30: Open to any Jewish person under the age of 30, and to any family where one member is Jewish and both are under 30. Student: Open to any Jewish person who is a full-time student.. Associate: Open to any Jewish person or family that includes a Jewish person if they are a member of another synagogue, provided they reside in Bozeman for three months or less in each year, or live permanently more than 75 miles from Bozeman. Affiliate: Open to any non-Jewish person who has been accepted into the conversion process, or who the Congregation believes is seriously exploring the possibility of joining the Jewish people, at the discretion of the Rabbi. Does not include voting rights. Friend: Non-member of Beth Shalom who provides assistance to the temple. As a “friend”, you receive information about the Congregation’s activities and invitations to participate in various activities. Does not include voting rights Address

Home Phone Cell Phone(s) Work Phone(s)

Email address(s) Names and birthdays of you and your family - including children if any ________________________________________________________________________ Anniversaries: ____________________________________________________________ Yahrzeit (Name, Date, Relationship to Member):

I do not have reliable access to email and will need newsletters mailed to the above address. I do not want to be listed in Congregation Beth Shalom’s Directory.

PAYMENT METHOD

Please indicate how you intend to make your contributions. We now offer monthly payments by automatic deduction. If you use this option, the bank will charge you a returned check fee if there are insufficient funds in your account to cover the withdrawal. Withdrawals will be made on the 15th of each month. If forms and auto payment authorization form arrive after 7/15, monthly payment amounts will be amended due to the shortened payment period. If you are electing this option for the first time, please fill out the bottom portion of the last page of this form and return it with a voided check Annually Semi-Annually Quarterly Monthly (auto-deduct)

Please fill this page out if you wish to switch to automatic payments

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH) I (we) hereby authorize Congregation Beth Shalom__________________________, hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account/ Savings Account (select one) indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to credit the same to such account. I (we) acknowledge that the origination’s of ACH transactions to my (our) account must comply with the provisions of U.S. law. Please attach a voided check associated with the account below. Forms must be returned to the temple administrator with signature not later than Friday, July 10. Bank Name________________________________ Branch____________________________ City_____________________________________ State______________ Zip__________ Routing Number________________________ Account Number___________________________ This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. Print Name Signature Print Name Signature Deduction will take place on the 15th of every month or the closest business day after the 15th, should the 15th fall on a holiday or weekend. Forms received after the 15th of a month will be processed the following month. Amount to be withdrawn: ______per month until advised in writing to discontinue. Family Affiliation $90/mo Individual Affiliation $56.67/mo Associate Affiliation $56.67/mo Affiliate Affiliation $56.67/mo Shalom Tots (ages 3-5) $30.83/mo Shalom Tweens (ages 6-9) $33.33/mo Shalom Kids (ages 10-12) $33.33/mo Other $_____ If you wish to contribute to the Building Fund, or to the Shomrim Society by direct payment from an account, please call our Administrator, Lisa Roots, 406 556 0528, and advise her of the amounts to be debited.