CERTIFICATE AUTHORIZING THE SALE OF CHAMETZ 5783

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Please submit this form no later than Tuesday, April 4th, 2023 at 8 AM.

All required fields must be answered in order to submit the form

MEMBERS: log into your account first and some fields will be filled in for you automatically.

AUTHORIZATION OF RABBI PERELSON

* Please check this box to confirm the following statement:

Please check this box to confirm the following statement:

I/we hereby authorize Rabbi Yisroel Perelson to dispose of all chametz that may be in my (our) possession; wherever it may be - at home, at my (our) place of business, or elsewhere - accordance with the requirements of Jewish Law as incorporated in the special contract for the sale of chametz.

HEAD OF HOUSEHOLD

* Last Name

* First Name

* e-mail address

RESIDENCE ADDRESS WITH CHAMETZ

* Residence Address Line 1

Residence Address Line 2

* City

* State

* Zip

BUSINESS AND OTHER ADDRESSES WITH CHAMETZ

Use the + button to enter as many business/other addresses as you need.

Business/Other Street Address

Business/Other City/State/Zip

HONORARIUM

Please consider an honorarium for Rabbi Perelson for acting as your agent in the sale of your Chametz.

Honorarium $

ELECTRONIC SIGNATURE

* Your Signature(s)

Head of household, and preferably all parties, sign with initials.

Sat, April 20 2024 12 Nisan 5784