Following are the details needed by Restorers of Zion in order to evaluate a request in your congregation for financial help. The more complete a picture we have of the needy person's situation, the more effectively we can meet the need.

This is only a guideline to make sure that essential questions are covered -- any additional information that you as the Shamash consider to be important can be included as well.

Any information that you supply to us will remain strictly confidential, according to the restrictions you specify below.  We ask that the same restrictions be observed among your own congregational leaders, so that together we can protect the privacy of the needy who turn to us for help.
 

1. Living circumstances

Name & address of applicant:

Visa status in Israel (citizen, permanent resident, tourist, etc.):
      If tourist, explain circumstances and applicant's reasons for living in Israel:

Number of dependents living at home with applicant:

2. Summary of spiritual condition and relationships

Standing of the applicant in your congregation (including how long you have known them):

Is the applicant submitted to the leadership of this congregation for spiritual guidance or correction when necessary? (this consent is necessary in order for your congregation to take spiritual responsibility for them)

Does your congregational leadership consider themselves responsible for the spiritual welfare of the applicant?

What kind of help has the congregation (or any other group) given the applicant in the past? (financial and/or other)

3. Financial information

Kind of financial help requested (one time or extended):
      If extended, how long will help be needed?

Amount of aid requested (as approved by Shamash):

Description of financial situation that led to this need:

Description of any other problems that contributed to the financial need:

Summary of monthly income & expenses (where extended help is requested):

General impression of applicant's financial condition from the home situation during your visit:

4. Recovery potential

Is the applicant suffering from a chronic financial need?
       If so, describe (as best as you can see) what problems are causing this chronic need:

Would any of the following help the applicant become more stable financially?
 Teaching on how to manage a personal budget
 Personal counseling
 Supervised spending (buying food or paying bills directly, rather than giving cash)
 Volunteer help (house repairs, child care, transportation, etc.)
 Training in a new job skill
 Other...

What kind of help can your congregation supply to this applicant? (financial and/or other kinds as mentioned above)

Does the applicant have the financial means to return the aid given (or part of it) at some later date, so that these funds can be recycled to help someone else?
      If yes, give time frame and terms suggested by the applicant:

Does the applicant have the ability and interest in helping others who are needy, in any of the other ways mentioned above?

5.  Confidentiality (three levels)

Please tell us which details in this application may NOT be made public - ie, in an open newsletter to supporters. (mark these items with a [*].)

Please also indicate which details may NOT be shared with anyone at all, including donor organizations and other helpers who will be involved in meeting this need.  (mark these items with a [**].)

In some cases, making details public may help the applicant to receive wider support.  If this is such a case, please note which details SHOULD be mentioned in an open newsletter. (mark these with the note: "advertise".)

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Submitted by (name of Shamash and congregation):

Date of application:

Date of visit to the applicant's home:
 

Additional comments: