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Application Form

Application for Subsidized Care

Application for Subsidized Care

Required Documents

Please include the following with this request:

  1. Three most recent paystubs
  2. A photo of your Teudat Zehut
  3. Bank statements from all accounts detailing the last three months
  4. Doctor's recommendation (Can be provided by our dentist)
Drop a file here or click to upload Choose File
Maximum upload size: 5MB
Make sure they are clear and legible or they will not be valid.
Drop a file here or click to upload Choose File
Maximum upload size: 5MB
Make sure they are clear and legible or they will not be valid.
Drop a file here or click to upload Choose File
Maximum upload size: 5MB
Make sure they are clear and legible or they will not be valid.
Drop a file here or click to upload Choose File
Maximum upload size: 5MB
Make sure they are clear and legible or they will not be valid.

I hereby declare that the information in this form as well as the required documentation is correct and complete. I am aware that providing false and/or incomplete statements will cancel eligibility for assistance from the fund immediately.

Sending
girl