Member Dues Renewal Form 2023-24

Please fill out the form below to make your 2023-24 Havurah Shalom dues commitment. If you would rather mail in a paper version, please print the file at this link, fill it out, and send it to Havurah Shalom, 825 NW 18th Ave., Portland, OR 97209.

The Standard Dues Chart is below for your reference and to calculate your dues.

Chart showing dues by household size and age

Chart showing dues by household size and age

Your Information

* First Name

* Last Name

* Email

* Age of Oldest Household Member

* What is Your Dues Category?

Single (Single Adult or Single Parent Household)Couple (Couple or Two-Parent Household)Associate (members of another synagogue or reside over 60 miles away)Double Chai ($3,600)Triple Chai ($5,400)

SECTION A: Full Dues Calculation for Members Not Making a Dues Adjustment

(Box A-1) Standard Dues

According to the standard dues chart above, what is the full annual dues amount for your Dues Category? Fill that amount in here.

(Box A-2) Voluntary Supplemental Dues?

If you are able, please consider adding to your full dues. Your extra contribution helps Havurah remain financially healthy.

(Box A-3) Total Dues Amount. Balance due by June 30, 2024.

Add amounts from boxes A-1 and A2, enter that total into Box A-3, and then please enter the amount from Box A-3 into Box C below*.

SECTION B: Dues Adjustment
Do you need to make a dues adjustment? You may self-adjust your dues according to your ability to pay, with a suggested annual minimum amount of 2% of your Adjusted Gross Income (line 11 of form 1040), but at least $360 per year for those who are 24 or older. You do not need to ask permission to self-adjust, nor will you be asked for proof that you are entitled to a dues adjustment. All self-adjustments are kept strictly confidential. We trust that when you are able, you will increase your level of support for the community.

(Box B-1) Standard Dues

According to the standard dues chart above, what is the full annual dues amount for your Dues Category? Fill that amount in Box B-1.

(Box B-2) Total Adjusted Dues Amount. Balance due by June 30, 2024.

Please fill in Box B-2 with the total amount you are able to pay in 2023-24, and then please enter the amount from Box B-2 into Box C below*.

SECTION C: Total 2023-24 Dues

Type the amount from box A-3 or B-2 into Box C below*. This is your total dues commitment for 2023-24.

* (Box C) Total Dues

*Sorry that you need to fill in your total dues amount twice on this form, but the interface between our online forms and our back-end accounting is imperfect. Thanks for your patience and understanding regarding this inconvenience.

Dues Payment

* Frequency of Payment

* Payment Method

Balance due by June 30, 2024.

If you choose "Automatic Debit" from the options above and you are setting up automatic debit for the first time, please fill out this form which gives us permission to take directly from your account.

Notes

Please enter any notes above if you want to pass along information. If you have questions about your dues, the Co-chair of our Finance Committee, Karen Westerman, would be happy to answer them. She can be reached at karen.westerman@havurahshalom.org.

If dues will come from a stock donation, please write in the "Notes" box above the following information: ______ shares of _________ which will come from ___________________ (name of broker). Transfer will be made by _________(month, year).

Fri, May 3 2024 25 Nisan 5784