Financial Aid

Zakat/Sadaqa Assistance Application Form

APPLICATION POLICY:

1) Any assistance provided in the form of sadaqa or zakat will be distributed only once per application request.

2) All requests for sadaqa or zakat funds must be made by filling out and submitting Application Form in advance. Please allow for reasonable time to process the application and, if the application is accepted, to distribute funds.

3) Confidentiality of the applicant and his or her application will be respected by MIC and its Zakat and Sadaqa Committee. However, we reserve the right to communicate with local religious institutions with a similarly situated committee, and the religious institution you designate in the application form below.

4) Erroneous or false information will automatically result in rejection of the application.

5) Eligibility for sadaqa or zakat will be based on a set of criteria established by the Zakat and Sadaqa Committee.

6) We reserve the right to request for additional information.

Please bring the following documents with you to expedite your application for assistance:

1) Driver’s license
2) Social Security Card
3) Any and all documentation to support your need for assistance

Section 1: Personal information

Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Phone
Field is required!
Phone
Field is required!
Phone
Field is required!
Field is required!
  • Sex:
  • Male
  • Female
Field is required!
Field is required!
  • Marital Status
  • Married
  • Single
  • Widowed
  • Divorced
  • Legally Separated
  • Informally Separated
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!

Section 2: Applicant's Circumstances

Number of Dependants
-
+
Field is required!
  • Place of Residence:
  • Own Home
  • Rental Apartment
  • Subsidized Housing
  • Shelter
  • Other
Field is required!
  • Means of Transportation:
  • Own Automobile
  • Public Transportation
  • Other
Field is required!
  • Employment Status:
  • Full-Time
  • Part-Time
  • Unemployed
  • Self-Employed
Field is required!

If Employed

Field is required!
Field is required!
Field is required!
Field is required!
Spouse Information:(if applicable) Is your spouse currently employed?
  • - select a option -
  • Yes
  • No
Field is required!
  • Health Insurance:
  • Insured
  • Uninsured
  • Public Aid
  • Medicaid/Medicare
  • Other
Field is required!
  • Eductaion:
  • College Grad or More
  • Some College
  • High School Grad
  • Some High School
  • No High School
  • Unknown
Field is required!
Statement of Circumstance:
Field is required!

Section 3: Need Assessment (Approximate) and Prior Zakat Receipt History

Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
  • Have you received assistance from or applied to other sources?
  • Yes
  • No
Field is required!
Field is required!
Field is required!
Field is required!

Section 4: References Please provide the names and phone numbers of anyone with whom you are familiar with, that can substantiate the information you provided above. Preferably, these references are non-family members and also attend the same religious institution (RI) you regularly attend.

Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Upload your Driver License
Upload your Document
Field is required!
Social Security Card
Upload your Document
Field is required!
Any and all documentation to support your need for assistance
Upload your documents...
Field is required!
Upload a Picture of your signature
Upload your documents...
Field is required!

Please read the following carefully before signing:

I (and, if appropriate, my spouse) have provided true and accurate information to the best of my knowledge and give consent to the Memphis Islamic Center Zakat and Sadaqa Committee to contact my designated religious institution and my witnesses for purposes of verifying and or supplementing the information in this application. I/we have attached a copy of my/our driver’s license, Social Security card, and any verifying documents related to this request. I/we also understand that the Committee may seek my or another insitution’s cooperation in resolving my situation.