Membership Dues Adjustment Request Form Membership Dues Adjustment Request Please fill out this confidential form to request an adjustment to your membership dues. Thank you! Names* Family Name First Name(s) PhoneEmail Please share your reason for requesting an adjustment.*Please certify your request:*I certify my statement above is correct and true to the best of my knowledge. I agree to making automatic monthly payments and will provide Congregation Bonai Shalom current payment method information. I understand that in addition to paying my adjusted amount I will be assessed a $10 per month fee to be applied to our building fund. Yes, I agree. No, I do not agree Please call me to discuss.