AMA Zakat Application

1

Send application to which organization?* This field is required.You can select only one. Please DO NOT submit multiple applications, your applications will be rejected

ICEV (Chandler Masjid)

ICL (Islamic Center of Laveen)

UICA (United Islamic Center of Arizona)

ACA (Arizona Cultural Academy)

MOVE (Muslim Outreach & Volunteer Enterprise)

ICNA Relief

ICC (Tempe Masjid)

2

Name* This field is required.

First Name

Last Name

3

Phone Number* This field is required.

Area Code

Phone Number

4

Email* This field is required.

example@example.com

5

Gender* This field is required.

Male

Female

6

Family Status* This field is required.

Single

Married

Divorced

Widow

7

Spouse Name

First Name

Last Name

8

Number of Dependents in the Household* This field is required.Include only minors or elderly dependents

9

Address* This field is required.Please enter a valid mailing address (approved checks will me mailed here)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

10

Government Issued ID* This field is required.

ID Type

ID Number

Date of Birth (mm/dd/yy)

Expiration Date (mm/dd/yy)

11

Copy of ID* This field is required.Please upload a copy of your ID document

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

12

Copy of Spouse IDPlease upload a copy of your ID document

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

13

Employment* This field is required.

Employment type

Average household monthly income

Average household monthly expenses

14

Zakat Request DescriptionPlease briefly describe your need for zakat. Make sure to enter the amount you are requesting assistance with.

15

Requested Assistance* This field is required.Select all that apply

Past due rent

Past due utility bills

Medical expenses

Food/drink/misc.

Other

16

Past due rent 5 day notice* This field is required.Upload a copy of your past due rent notice

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

17

Past due utility bill* This field is required.Upload a copy of your past due bill

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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