Zakat Application

Application For Zakat

Please fill out the form Carefully
Introduction

We care about our community members. Many people in our community are struggling with financial hardship and distress. We have Zakat funds available, which have been donated by many generous community members. If you are in a state of financial difficulty and believe that you are Zakat-eligible, please complete the form below. This form is to be completed by any individual or head of the household seeking Zakat funding from Zakat of ICM. We will be sure to get back to you within one week with a response about how we can help you. Submission of an application by an applicant (Recipient) does not constitute an obligation on ICM to approve the form, and is contingent on availability of funds and ICM local community members' needs. We pray that Allah makes things easier for you.
Application Status*
Legal Name*

First NameMiddle NameLast Name
Gender*
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)*
Please enter a valid phone number.
Cell Number*
Please enter a valid phone number.
Email*
example@example.com
Marital Status*

SingleMarriedDivorcedWidow/Widower
Please list the name of your children and their respective ages. 1-Name/Age 2- Name/Age 3-Name/Age
Name of spouse . 1-Name/Age*
Work Status*

EmpolyedPart TimeFull TimeUnemployedDisable
Have you received assistance from ICM before? * If yes, how much& when? * .
Are you currently receiving any financial assistance from your local Islamic center? * If yes, how much? * If no, why not? *
Income Information
Total Annual income*
Add total income from all sources including those below.
Income Sources (Check all Apply)*
Zakat
Amount Requested*
Please, state the reasons for seeking financial assistance in detail and your plan to recover.*
How this amount will be used?(e.g. paying rent, health, education, and etc.....) Also explain how this financial will support your recovery plan *
Reference

Please provide the following information for two references
Reference #1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #2*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Documentation
Types of documentation needed shall vary from case to case.

All cases require the following documentation to be uploaded.
1. Photo ID
  - Driver's license.
  - Passport.
  - School ID.
2. Last year's tax return.
3. Most recent 4 statements for bills from payee or equivalent.
4. Proof of residence.
Other pieces of documentation that are needed on a case by case basis are:
1. Income statements.
2. Bank statement for past 90 days.
3. Court orders, eviction notices SSI and/or other government program eligibility letters.
Please upload all the items to this form
Picture ID
Cancelof
File Upload*

Last year's tax return
Cancelof
File Upload*

Most recent 4 statements from payee or equivalent
Cancelof
File Upload*

Proof of residence
Cancelof
Certification & agreement

Applicant Sign Below. By signing, I certify that the information I submitted is accurate and truthful, and that I agree to the disclaimer, requirements and all terms and conditions in this form. I further agree to not hold ICM, its board members, officers, employees, and agents and any donors funding this grant liable from any claims, demands of action I may have against ICM as a result of omission, acceptance, rejection, suspension, or termination of my application. I further understand that even if I am eligible for support, I may not receive any assistance if funds are not available.
Applicant Name*
Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
For ICM Office Use Only
Date

MonthDayYear
( ) Approved a donation of $blanks .( ) Disapproved due to blank .
Should be Empty:

Application For Zakat

Introduction

Income Information

Zakat

Reference

Documentation

Please upload all the items to this form

Certification & agreement

For ICM Office Use Only