Zakat-financial Assistance Form 08.pages

MASJID DARUL QURAN 1514 East Third Avenue, Bay Shore, NY 11706 Phone: 631-665-9462 Fax: 631-665-0233 Zakatul Mal Fund Financial Assistance Request Form Name:

________________________________________[ ] Single [ ] Married

SS #

_______________________

Phone ®

_____________Work Phone: ____________Cell Phone_____________

Current Address: City:

Driver ID: ___________________

_____________________________________________________

________________ State:

____________

Zip Code:

______

Previous Address: _______________________________________________________ No. Of Dependents: ___________________________

Reason for Financial Assistance

________________________________________________________________________ Signature of Applicant (I hereby confirm that the information provided on this form is current and correct) Amount Requested:

$ __________________

Request Reviewed by: ________________________________________________ Need Additional Information [ ] Yes [ ] No Applicant advised of the type of additional information required to further consider the request. Recommendation based on:

[ ] Interview [ ] Personal knowledge

Committee Recommendation

[ ] Yes

Amount Approved: $________

Approved by: _________________

Mode of Payment

[ ] Cash

__________________ Signature of Applicant

[ ] Check

[ ] No

Payment Received: