ICN Zakat Request Form

Zakat Assistance

Request Form
Purpose: This form is to identify individuals and families in Middle TN who are elgible for assistance from the Zakat fund. Please make sure to visit our website www.icntn.org/zakat for details on the zakat process, review time frame, and policy.

Policy Summary:
- Applicants must complete this Zakat form and present additional supporting documents when requested.
- The maximum approval amounts for a 12 month period are $200 for individuals and $500 for families.
- Approved assistance will be disbursed in the form of card or check payment to the entity(s) the applicant is indebted to (NO payments will be made directly to applicants).
- The process may take up to 10 days for approval and disbursement.
- Zakat assistance is limited to applicants in Middle Tennessee and fund availability.
- Applicant (and their household) must be be eligible for “Zakat” according to the Holy Qur’an (9:60).
- Applicants may be disqualified for assistance if knowingly provided false information.
Instructions:
- Click "Next" to continue completing the following form.
- You will be asked to "Review Answers" before "Submit" to complete.
- Items marked with an asterisk (*) require a response.
- You can save your responses to complete later by clicking on "Save for Later".
- Before beginning the form make sure to gather applicant information, household information, a picture of applicant ID, copy of bills needing assistance paying, and any supporting documents to support the case (e.g. most recent tax return, bank statements, etc.).
- This form will take approximately 15-20 minutes to complete.
Have questions? Email zakat@icntn.org, call or text 615-200-0379, or message us on WhatsApp.
Zakat Case Number - Previous Applicant*
First-time applicant?*
Click to select

Your Information
Your Relation to Applicant*
Click to select
Your Name*

First NameLast Name
Your Phone Number*
Your Email*
example@example.com

Organization Information
Note: By completing this section, you, as a representative of the non-profit organization are requesting ICN to disburse the necessary funds to the non-profit organziation listed below, in which the funds will only be used to assist the applicant. This is only for cases in which the non-profit organization has vetted the applicant and it would be a burden to request the applicant to apply to ICN seperately.
Your Position within Organization*

Board MemberImam/Religious LeaderOffice ManagerSocial WorkerOther
Organization Name*
Tax ID*
Organization Phone Number*
Organization Email Address*
example@example.com
Organization Mailing Address*

Street Address

Suite Number, if applicable

CityState

Zip Code

Applicant Information
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 ID*

Please make sure the picture is readable
Cancelof
Applicant's ID Number*
State Driver License/ID or Passport

Applicant's Household Information
List ALL persons living in the "Household" (including applicant)*

Is anyone in your "Household" receiving government benefits?*

Unemployment benefitsSNAP (Food Stamps)SSI/SSDI (Supplemental Security Income/Social Security Disability Insurance)WIC (Special Supplemental Nutrition Program for Women, Infants, and Children)Medicaid or Child's Health Insurance Program (CHIP)TANF (Welfare or Temporary Assistance for Needy Families)Section 8 (Housing Assistance)Not Receiving Government BenefitsOther
Has anyone in your "Household" applied for assistance in the last 6 months from any other organization?*

Masjid or other Nonprofit OrganizationLocal, State, or Federal GovernmentNot Applied for Assistance within last 6 monthsOther
How much financial assistance have you (or anyone living with you) received from the Islamic Center of Nashville (12South & Bellevue) in the last 12 months?*
Is anyone in your household related to any employee, board member, or substantial donor of the Islamic Center of Nashville (12South or Bellevue)*
Click to Select

	Amount ($)
Wages
Alimony
SSI/SSDI
Friends/family Assistance
Unemployment Benefits
Charity Assistance
Child Support
Other Income

	Amount ($)
Rent
Utilities
Medical Bills
Car Payment/Insurance
Telephone/Internet Bill
Transportation
Food/Groceries
Other Expenses

	Balance ($)
Bank Accounts (Checking/Saving)
Investments
Other Assets

Bill Provider Information
List the bill(s) you need assistance paying*
Upload a copy of the bill(s) listed above*

*You must upload a copy of ALL bills listed. Please make sure pictures are readable and include entire document
Cancelof

Travel Information
What Type of Travel Assistance Are You Needing?*

Need A Ride LocallyTravel Out-of-Town
Pickup Location*

Street Address and Suite Number

Street Address Line 2

CityState

Zip Code
Destination Location*

Street Address and Suite Number

Street Address Line 2

CityState

Zip Code
Origin*
Destination*
Passenger Information*

Accommodation Information
Number of Nights Needed*
Guest Information*

Applicant's Supporting Documents
Attach additional documents to support your case

*Examples: Most Recent Tax Return for ALL Household Members, Most Recent Bank Statement(s) for All Account(s), Eviction Notice, Disconnection Notice, etc.
Cancelof

Applicant's Reference Information
References: List individuals/entities who can confirm and verify the information on this application*
Which masjid do you frequently attend?*
Click to Select
How did you find out about our Zakat program*

ICN websiteFriend/Community LeaderOther

Applicant's Interview Preference
Are you able to communicate in English?*

YesNo
Can you provide an interpreter?*

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?*

Declaration and Submit
Organization Representative Signature*

Clear
Applicant Signature*

Clear
Should be Empty:

Zakat Assistance