CAP Application

COMMUNITY ASSISTANCE PROGRAM (CAP) - APPLICATION
If you are in need of financial assistance, please complete the Electronic Application below and upload your supporting documents into that. Please be advised that, due to limited resources, we are not able to offer assistance to residents outside of Orange County.

Supporting Documents

Applicant’s Driver License or valid photo ID

Spouse’s Driver License or valid photo ID (if applicable)

Lease agreement (if applicable)

Award letter from SSI, if you receive Food Stamps or Cash Aid (if applicable)

Last two (2) bank statements (if applicable)

Pay stubs for the last two (2) months (if applicable)

Last year’s tax return (if applicable)

Applicant’s Resume/CV (if you are looking for a job)

College Transcript (if applicable)

Any other statement(s) that will help your case

Please don’t hesitate to contact the office at the number below, should you have any questions or concerns.
Applicant's Personal Information
Name*

First NameLast Name
Social Security*
Write number without dashes
Date of Birth*

MonthDayYear
Mobile Number*
Write number without dashes
Home Phone Number
Write number without dashes
Email*
Marital Status
Are you married?*
Spouse - Name*

First NameLast Name
Spouse - Social Security #*
Write number without dashes
Spouse - Date of Birth*

MonthDayYear
Spouse - Phone Number*
Write number without dashes
Spouse - Email*
Address
Are you Homeless?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide three references who can verify that you are homeless
Reference #1 - Name*

First NameLast Name
Reference #1 - Relationship*
Reference #1 - Phone Number*
Write number without dashes
Reference #2 - Name*

First NameLast Name
Reference #2 - Relationship*
Reference #2 - Phone Number*
Write number without dashes
Reference #3 - Name*

First NameLast Name
Reference #3 - Relationship*
Reference #3 - Phone Number*
Write number without dashes
Dependents
Do you have any dependents?*
Dependent 1 - Name*

First NameLast Name
Dependent 1 - Gender*
Dependent 1 - Age*
Dependent 1 - Grade*
If not applicable, write N/A
Dependent 1 - Name of School*
If not applicable, write N/A
1. Do you have another dependent?*
Dependent 2 - Name*

First NameLast Name
Dependent 2 - Gender*
Dependent 2 - Age*
Dependent 2 - Grade*
If not applicable, write N/A
Dependent 2 - Name of School*
If not applicable, write N/A
2. Do you have another dependent?*
Dependent 3 - Name*

First NameLast Name
Dependent 3 - Gender*
Dependent 3 - Age*
Dependent 3 - Grade*
If not applicable, write N/A
Dependent 3 - Name of School*
If not applicable, write N/A
3. Do you have another dependent?*
Dependent 4 - Name*

First NameLast Name
Dependent 4 - Gender*
Dependent 4 - Age*
Dependent 4 - Grade*
If not applicable, write N/A
Dependent 4 - Name of School*
If not applicable, write N/A
4. Do you have another dependent?*
Dependent 5 - Name*

First NameLast Name
Dependent 5 - Gender*
Dependent 5 - Age*
Dependent 5 - Grade*
If not applicable, write N/A
Dependent 5 - Name of School*
If not applicable, write N/A
Employment
Do you have a job?*
Current Occupation*
Name of Current Employer*
Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone Number*
Write number without dashes
Are you looking for a job?*
Please list all the skills that you have*
Please list any credentials/education that you feel is relevant for your field of work:*
Does your spouse have a job?*
Spouse - Current Occupation*
Spouse - Name of Current Employer*
Spouse - Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse - Employer's Phone Number*
Write number without dashes
Bank Account Information
Do you have a bank account?*
Current Checking Account Balance*
Current Saving Account Balance
Monthly Income
What is your monthly income (from work)?*
If not applicable, write N/A
What is your spouse monthly income (from work)?*
If not applicable, write N/A
Do you receive Social Security Pensions, EBT or Cash Aid?*
Social Security Pensions*
If not applicable, write N/A
Food Stamps (EBT)*
If not applicable, write N/A
Cash Aid*
If not applicable, write N/A
Other source of income*
If not applicable, write N/A
Do you receive Unemployment?*
How much?*
How long have you been receiving it?*
Monthly Expenses
Rent*
If not applicable, write N/A
Utilities (e.g. Electricity, Water, Gas, etc.)*
If not applicable, write N/A
Food (Average)*
If not applicable, write N/A
Medical (Average)*
If not applicable, write N/A
Assets Information
Do you have any assets?*
Item 1*
Value 1*
1. Do you have any other assets?*
Item 2*
Value 2*
2. Do you have any other assets?*
Item 3*
Value 3*
Nature of Help Requested
Is this application for college scholarship?*

YesNo
Provide a brief explanation of the financial support you are requesting*
List financial support you are receiving from other people or other organization(s):*
Authorization for Release of Information
I authorize the exchange of information between the Rahma Center and the Zakat Collective organizations. I release all parties involved from liability and responsibility for information related to my case*

I authorize
I hereby certify and verify that all of the foregoing information given is true and correct to the best of my knowledge and belief.*

I certify and verify all information is correct
Signature*
Today's Date*

MonthDayYear
Applicant’s Driver License or valid photo ID*

Cancelof
Spouse’s Driver License or valid photo ID*

Cancelof
Lease agreement (if applicable)

Cancelof
Last year’s tax return (if applicable)

Cancelof
Most recent bank statements*

Cancelof
Second most recent bank statements*

Cancelof
Pay stubs for the last two (2) months*

Cancelof
Award letter from Social Services or SSI, if you receive EBT or Cash Aid*

Cancelof
Applicant’s Resume/CV (if you are looking for a job)

Cancelof
Transcripts*

Cancelof
Any other statement(s) that will help your case

Cancelof
Administrative Items
Notes
Case Manager
Should be Empty:

COMMUNITY ASSISTANCE PROGRAM (CAP) - APPLICATION

Applicant's Personal Information

Marital Status

Address

Dependents

Employment

Bank Account Information

Monthly Income

Monthly Expenses

Assets Information

Nature of Help Requested

Authorization for Release of Information

Administrative Items