Zakaat Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
E-mail
example@example.com
Residence
*
Owned
Mortgage
Lease
Shelter
Gender
*
Male
Female
Marital Status
*
Single
Married
Divorced
Widowed
Number of children, if any
*
Employment Status
*
Full Time
Part Time
Self Employed
Unemployed
Employer Name and Job Title
*
Household Annual Income
*
Amount everyone in your home make altogether in a year
Health Insurance Information
*
Medicaid, Medicare
Other Insurance
Uninsured
Public Aid
Education Level Completed
*
Haven't completed High School or received GED yet
High School or GED
Trade School
College
Means of Transportation
*
Car (Make, Model, Year), Public Transportation, Family Members, etc.
Household Monthly Expenses
*
List of monthly bills and amounts
Please list any assets
*
Owned property, vehicles, jewelry savings accounts, stocks, etc.
Please list your debts
*
To who and amounts
Zakat received
*
Public aid you are currently receiving or have received in the past year
LINK / Food stamps
Medicare / Medicaid
Social Security Benefits
Temporary Needy Family Assistance
Subsidized Housing / Public Housing
Statement of circumstance:
*
Describe the reasons you are requesting Zakat aid. How much do you need, and how assistance for all or part of the total from the Zakat fund will meet your needs. Please be specific.
Submit
Should be Empty: