Zakat Donations For Local Community Only

To ensure the proper distribution of Zakat funds, every applicant must submit clear copies of the following:

  1. Photo ID: For the applicant, spouse and all dependents; Driver’s License, State I.D. or Passport
  2. Social Security Card (For all those that provided photo ID as identification.
  3. Lease Agreement (If renting)
  4. Proof of income (i.e. last pay stub)
  5. Other documentation that might help in the evaluation; such as medical reports, receipts, billing statements, etc.

All fields are required on this form except where noted “Optional”. All information is confidential and intended only for restricted internal use by authorized Zakat committee personnel and used exclusively for evaluation of Zakat requests. Please attach/upload the scan/picture of the identification proof you will use.

Your Name

Your Email

Application Date

Date Of Birth

Are you a "Citizen" or "Permanent Resident" or "Legal Resident" of U.S.? YesNo

Select One Identification Proof
Driver's LicensePicture I.D.Passport . Enter the I.D. #

Please Attach/Upload scanned or picture Files for the ID you selected above:

Information Needed For Head of Household/Family

Street Address

City

State

Zip

Phone Primary

Alternate Phone (Optional)

Marital Status
SingleMarried.Divorced

Total Household Monthly Income: $

Place of Residence
OwnRentalRoom RentalShelterLow-Income HousingOther :

Expenses

Rent: $

Utilities: $

Other: $

NUMBER OF FAMILY MEMBERS:
(Including yourself)

Enter each name and age separated by comma below

Employment Status
Full TimePart TimeUnemployedSelf-Employed

Other Need: Detailed reasons for requesting assistance (Please be specific)

Have you applied for Zakat assistance before?
YesNo

If YES, When?

REFERENCES: Please list at least 2 individuals-references who can confirm and verify the information you have provided on this application. References should not be immediate relatives, people who live with you or current zakat recipients.

Reference No. 1 - Name:

Phone:

Relationship:

Reference No. 2 - Name:

Phone:

Relationship:

Applicant Signature: (Enter Full Name)

Signed (Date):

I have read and understand the criteria for considering my application for zakat. (If YES, Please check box)

Contact us: zakat@aishacenter.com