COURAGE TOGETHER FINANCIAL ASSISTANCE APPLICATION FORM
Name
First Name
Last Name
Address
Post Code
Email
*
example@example.com
Phone Number
*
Why are you requesting a grant from Courage Together?
*
How much are you applying for?
*
Have you applied to any other sources for funds? If yes, please detail
*
What will the funding provide?
*
What benefits do you currently receive? (eg PIP, Disability living allowance, Universal Credit, Child Benefit, Carers Allowance, etc) Please list all benefits along with the amounts paid and if weekly or monthly
*
Are you currently employed?
*
Please Select
Yes
No
If Yes, where and indicate income (weekly, monthly)
What is your monthly rent/mortgage
*
If you have any debts please list below to whom and the amount owed
*
Do you have any expenses apart from usual food, electricity, etc? If so please detail
*
How many dependants do you have?
*
Please tell us your relationship to the dependants and their ages
*
How many of these dependants live in your house?
*
Please tell us what family you have apart from your dependants above (sisters, brothers, parents, children etc) and where do they live
*
Are you Zakat eligible?
*
Please Select
Yes
No
If YES then please accept the declaration: I have no saving above the amount of nisaab (currently £367.23)I declare am not from the lineage of the prophet Muhammad SAW
Please Select
I accept the declaration
DECLARATION You confirm that you will provide evidence of expenditure (if relevant/requested).You confirm that you will provide photographic evidence of your identity.You confirm you will supply 3 months bank statementsYou confirm you will supply an original benefits letterYou confirm you are MuslimYou confirm you have no family supportYou confirm that you will provide evidence of your current address.
*
Agree
I testify in front of Allah that the facts stated and the information provided on this form is true and accurate to the best of my knowledge and belief. I understand that I may be acting unlawfully and committing a criminal offence if I make, or cause to be made, a false statement on this document without an honest belief in its truth. I understand that if Courage Together considers I have made a false or misleading statement on this form, it may take action as deemed appropriate including reporting matters to the relevant authorities.
*
Agree
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Continue
Continue
Should be Empty: