Zakat Application
Muslims Understanding and Helping Special Education Needs
Please complete the application below and attach all relevant supporting documentation.
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Personal / Background Information
Name of Person Requesting Zakat
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security #
*
Drivers License #
*
Home Phone
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
Amount of Zakat Requested
*
Applicant Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Needed for (purpose)
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Needed for (purpose)
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Please Select
Housing Instability (rent/mortgage payments/homeless)
Livelihood Support (Low/No income)
Food Insecurity
Debt Relief
Emergency Assistance
Medical Expenses
Special Needs (Disability) Support
Explanation of Situation
*
Assessment of Financial Assistance
Marital Status
*
Please Select
Single
Married
Divorced
Do you have a disability?
*
Yes
No
Does one of your dependents have a disability?
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Yes
No
Name of Household Member with a Disability
*
First Name
Last Name
Type of Disability
*
Type of Disability
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Please Select
Attention-Deficit/Hyperactivity Disorder
Autism
Blindness
Cerebral Palsy
Deafness
Developmental Delay
Down Syndrome
Epilepsy
Hearing Impairment / Hard of Hearing
Learning Disability
Muscular Dystrophy
Learning Disability
Speech Impairment
Physical Disability
Other
Other: Please Specify
*
Please upload documentation/proof of disability
*
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Age
*
Household Size:
*
Names of all children living in household and age (ex John Doe, 25):
Do you pay rent/mortgage?
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Yes
No
If YES, how much per month?
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Automobile
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Own
Lease
If LEASING, how much per month?
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Employed?
*
Yes
No
Health Insurance
*
Approximate Total Monthly Household Income
*
Please list all sources of household income. Include values.
*
Please upload proof of all sources of income listed below.
*
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Approximate Total Monthly Expenses
*
Total Value of Savings (stocks, bonds, cash, jewelry, etc)
*
Have you received Zakat from other sources? Please include government assistance, social security, disability payments, food stamps, etc.
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Yes
No
If YES, explain here. Please include: government assistance, social security, disability payments, food stamps, etc.
*
Bank Account Number
*
Routing Number
*
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Documentation
Please include identification & all papers that verify or are related to your situation, lease eviction notice, hospital letter(s), termination letter(s), injury report(s), other benefit termination letter(s), reference letter(s), etc.
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References
Please list the information of 2 individuals who know of your situation
Name of Person 1
*
First Name
Last Name
Relative
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Person 2
*
First Name
Last Name
Relative
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your application will be reviewed by one of our Sheikhs for eligibility shortly. If eligible, payment will be sent to you through ACH.
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If you do not have a ACH, let us know below and a staff member will reach out to you to coordinate payment.
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