ICN Zakat Al Fitr Request Form

Zakat Al-Fitr

Request Form
Application Deadline: Friday, March 6, 2025 at 11 PM

Purpose: This form is to identify individuals and families in Middle TN during the holy month of Ramadhan who are elgible for Zakat Al-Fitr.

Instructions: If you live in Middle TN and feel that you are Zakat elgible, please click "Next" to continue completing the following form and we will get back to you as soon as possible. Before beginning the form make sure to gather a picture of your ID and bank deposit information (to receive via direct deposit). This form will take approximately 7-10 minutes to complete.

Disclaimer: Completing this form does not guarantee approval as it depends on determination of "need" and the availability of funds.

Have questions? Email zakat@icntn.org, call or text 615-200-0379.
Pantry Case Number - Confirmed*
This case number is based on the sequence of applicants. Correct if out of order and enter the original case for previous applicants.
- Your Relation to Applicant*
  Click to select
- Your Name*
  
  First NameLast Name
- Your Phone Number*
- Your Email*
  example@example.com

- Name*
  
  First NameLast Name
- Phone Number*
- Email
  example@example.com
- Address*
  
  Street Address
  
  Apartment Number, if applicable
  
  CityState
  
  Zip Code
- Upload a Picture of the Applicant's Gov't Issued ID*
  
  Please make sure the picture is readable
  Cancelof
- Applicant's ID Number*
  Government Issued ID: State Driver License/ID or Passport
- Work Status*
  Click to select option
- Household Size*
  (Including yourself, other adults, and children living with you)
- What type of essentials is your household struggling with?*
  
  Help to Pay Rent, Utilities, or Other BillsHelp to Buy Food, Clothing, or Other NecessitiesHelp with ShelterHelp with Medical Bills/PrescriptionsNoneOther
- Which of the following scenarios best describes your hardship situation?*
  
  Permanent DisabilityPoverty-strickenRefugeeTemporary DisabilityTemporary Need (temporary financial constraints)Terminally IllUnemployed - Cannot WorkUnemployed - Still Looking for a JobOther
- You can explain your situation in more detail here:
  *Optional
- What is your household estimated monthly income range?*
  Please include ALL income sources such as money from work, alimony, government, and private institutions
- What is your household estimated monthly expenses range?*
  Please include ALL types of expenses such as rent, utilities, medical, food, and any loans/credit debt
- Is anyone in your household related to any employee, board member, or substantial donor of the ICN (12South or Bellevue)*
  Click to Select
- Which masjid do you frequently attend?*
  Click to Select
- How did you find out about our Zakat program*
  
  ICN websiteFriend/Community LeaderOther
- Provide a reference who can confirm the information you put on this form
- Are you able to communicate in English?*
  
  YesNo
- Which language do you need an interpreter for? (We will do our best to find an interpreter, but cannot guarantee)*
- When is the best time for us to contact you?*
- Do you have a bank account? (to receive funds via ACH)*
  Click to Select
- Enter your bank account information*
- Upload a picture of a voided check (optional)
  
  Click on the box to upload
  Cancelof
- Signature*
  
  Clear
Should be Empty:

Zakat Al-Fitr