HFLA MENTAL HEALTH, DISABILITY, AND INCLUSION APPLICATION

APPLICANT PERSONAL INFORMATION

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Indicate your relationship to the Jewish community.*

I am Jewish.
My spouse/partner is Jewish.
I am not Jewish, but I work for a Jewish communal agency.
I am not Jewish and have no connection to the Jewish Community.

Name of Jewish Agency you work for:*

US Citizen or Legal Resident?*

Yes
No

Specify anyone (person or organization) who referred you to HFLA:

If Other, please give details

FAMILY INFORMATION

Applicant's Marital Status*

Spouse's Name

First Last

Spouse's Email

LOAN INFORMATION

Have you received an interest-free loan before?*

I am a first-time HFLA Applicant.
I am currently paying towards an HFLA loan.
I have paid off a previous loan from HFLA.
I have received a loan from another Hebrew Free Loan agency.
I have guaranteed a loan but not applied for one myself.

Amount Requested*

(Up to $7,500 with Guarantor)

General Purpose of Loan (i.e. debt, medical, home repairs, etc.)*

More specifically, how will you use the loan money?*

GUARANTOR* INFORMATION

(*To qualify for a loan greater than $1,000, Guarantor must be someone different from Borrower. See FAQ for more information.)

Name of Guarantor*

First Last

Guarantor's Relationship to Applicant*

cannot be self or spouse

EMERGENCY CONTACT

Your emergency contact will not be used for collections. This person(s) has your permission to discuss loan and payment details with HFLA in the event of an emergency.

Emergency Contact 1*

First Last

Relationship of Emergency Contact 1*

Emergency Contact 2

First Last

Relationship of Emergency Contact 2

BANKING & EQUITY

Bank Name*

Amounts Held

Stocks, Mutual Funds, or other investments excluding 401k

APPLICANT EMPLOYMENT & INCOME

Employed Since

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

SPOUSE EMPLOYMENT & INCOME

(if applicable)

Spouse's Occupation

Name of Spouse's Employer

Take-home Pay (after taxes) per month

Employed since

TOTAL INCOME

Other Income Listed (alimony, retirement pension, child support, etc)

$ Total "Other Income" from Above*

(enter 0 if not applicable)

Total Monthly Household Net Income

take-home pay + other income

MONTHLY EXPENSES

Medical Insurance (if applicable)*

How many months remaining on car payments?

Other Monthly Expenses (synagogue dues, entertainment, subscriptions, school tuition, etc.)

$ Total "Other Expenses" from Above*

(enter 0 if not applicable)

Dependent(s) Care Expenses (daycare/preschool, private school, religious school, after care, child support)

Total Monthly Expenses

MONTHLY NET=

Total Net Income MINUS Total Monthly Expenses

Monthly Net

DEBT

*Please note all applicants are required to submit a free credit report.

Credit Card Balance(s)*

For each credit card, please list (1) name (2) balance and (3) how much you pay monthly.

Student Loans

Other Debt: Please list name of creditor, type of debt, amount, monthly payment and date last paid. (i.e. line of credit, personal loan)*

Have you ever filed for bankruptcy?*

Yes
No

Required Supportive Documentation for Applicants. Please email to loans@hfla.org.

1. Copy of your driver's license (or other valid picture ID) 2. Most recent employer pay stub 3. Most recent W-2 4. Most recent tax return 5. Most recent proof of mortgage or rent payment 6. Most recent utility bill 7. Free Credit Report: www.annualcreditreport.com (*save as PDF for email)

Upload as many of the following documents of support that you have available. Please email all remaining documents to loans@hfla.org as soon as possible.

Please explain how you will have the monthly resources to make the loan payments to HFLA.*

The undersigned hereby certifies that the information provided is true, correct and complete. HFLA is authorized to make inquiries and gather information that it feels is necessary concerning statements made on this application. It is further agreed that HFLA will be promptly notified of any material changes in this information.

Applicant's Name*

First Last

Consent*

I agree to the terms of this application and loan.

Today's Date*

CAPTCHA

MENTAL HEALTH, DISABILITY, AND INCLUSION LOAN APPLICATION

MENTAL HEALTH/DISABILITY LOAN APPLICATION

APPLICANT PERSONAL INFORMATION

FAMILY INFORMATION

LOAN INFORMATION

GUARANTOR* INFORMATION

EMERGENCY CONTACT

BANKING & EQUITY

Amounts Held

APPLICANT EMPLOYMENT & INCOME

SPOUSE EMPLOYMENT & INCOME

TOTAL INCOME

MONTHLY EXPENSES

MONTHLY NET=

DEBT

Required Supportive Documentation for Applicants. Please email to loans@hfla.org.

Upload as many of the following documents of support that you have available. Please email all remaining documents to loans@hfla.org as soon as possible.

CONTACT US