Embed Size (px)
Citation preview
425N.AlmaSchoolRd.ChandlerAZ85224|Phone:(480)442-7783|[email protected]
1.Pleasecompletebothsidesofthisform2.Makesureyoureadandcompleteeachsectioncarefullyandthensignattheendoftheform3.AttachacopyofthefrontsideofyourID/License4.Attachsupportingdocumentssuchaspastduebillnotices,evictionnoticesetc.
FullNameFirst Middle Last
Street Apartment#
City State ZipCode
Phone/EmailPhone# Emailaddress
GovernmentIssuedID IDnumber Expirationdate DateofBirth
SpouseNameFirst Middle Last
Numberofchildren Listages
Otherdependentsinhousehold
EmploymentStatusEmployed: Yes No Employmentstatus: FullTime PartTime
Total
AssistancefromotherMasajid
MonthlyIncome(Listpercategory)
IncomeSource Amount
Salary
FoodStamps
GovernmentAssistance
Other
Section3:Employment&Income
Section1:PersonalInformation
Address
FormInstructions
Section2:Family&Dependents
Children&OtherDependents
IslamicCenteroftheEastValleyZakatApplicationForm
Complete nextpage
Page1/2
425N.AlmaSchoolRd.ChandlerAZ85224|Phone:(480)442-7783|[email protected]
Approval(ICEVUseOnly)
Referencepersonforcase Name ContactNumber Relationship
PLEASEREADCAREFULLYBEFOREYOUSIGN1.Iconfirmthattheinformationprovidedaboveiscorrectandaccuratetothebestofmyknowledge2.IunderstandthatICEVZakatfundsarelimitedandisdistributedbasedonneedpriority3.IunderstandthatIcanonlyapplyforZakatassistancefromICEVamaximumofonceperquarter(3months)4.IunderstandthatImustalsosupplementthisapplicationwithacopyofmyIDaswellascasesupportingdocuments5.IunderstandthatICEVmaysharemyapplicationinformationwithotherMasajid/OrganizationsZakatDirectors6.Onceapplicationandallnecessarysupportingdocumentsarereceived,youwillbecontactedbytheICEVZakatAdmintogooveryourapplication,thenitwillbesubmittedforfinalapproval/processing.Thisprocessusuallytakes3-5days.
Name Signature Date
Section5:AcknowledgmentandSignature
Section6:FormSubmission
Amount
RequestDetails
Category
PastDueRent
PastDueUtilityBills
MedicalExpenses
Food/Drink/Misc.Expenses
Other(specify)
Total
Section4:ZakatRequest
CaseDescriptionPleasebrieflydescribeyourcaseandneedfor
zakat
IslamicCenteroftheEastValleyZakatApplicationForm
ApplicationscanbesubmittedattheICEVsuggestionboxinthelobbyorbyemailingaclearscannedcopytotheemailaddressinthefooterbelow.
Page2/2
