Name:

Address:

Telephone:

Birth Date: Sex: __M __F

Marital Status: __Married __Single __Divorced __Widowed

Dependent

Children: (1) Name___________________ Birth Date:_________

(2) Name___________________ Birth Date:_________

(3) Name___________________ Birth Date:_________

(4) Name___________________ Birth Date:_________

Other persons in household:

(1) Name___________________ Age:_________ Relation________

(2) Name___________________ Age:_________ Relation________

(3) Name___________________ Age:_________ Relation________

(4) Name___________________ Age:_________ Relation________

Name, address and PHONE of mosque at which you attend Jum`a

Financial Status:

Monthly income (from all sources): __________________

Monthly expenses: accommodations_____________________

___rent __mortgage

Transportation______________________

(include car payments)

Medical Bills_______________________

(average over last 2 years)

Food_______________________________

Net assets (value of all your possessions):____________

Situation:

Describe reasons for which aid is sought. State the reason you are in need, how much you need, and how assistance for all or part of the total from the Zakat Foundation will meet your need. Be specific:

I have read and signed the accompanying notice of disclosures and waivers. I grant the Islamic-American Zakat Foundation permission to contact my masjid and my witnesses for purposes of verifying and/or supplementing the information in this application. I also understand that the Zakat Foundation may seek my another local masjid’s cooperation in resolving my situation and that I may be asked to participate in the MEDINA program as a condition of any grant or assistance. I solemnly witness that there is no god but Allah and that Muhammad is His messenger, and that the foregoing information is true to the best of my knowledge.

__________________________ ____________

Applicants's signature Date

Witnesses:

We the undersigned solemnly witness that there is no god but Allah and that Muhammad is His messenger, and that the above information is true to the best of our knowledge.

(1) Name:

Address:

City: State: Zip: Telephone:

Signature: _____________________________________

(2) Name:

Address:

City: State: Zip: Telephone:

Signature: ______________________________________

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Committee Decision: (for Foundation use only)

Signatures of Review Committee:
 
 
 
 
 
 
 

This document is a part of the Islamic-American Zakat Foundation ("the Foundation") application process. No application will be considered unless this form has been read and signed by the applicant. This is an explanation of the procedures of the Islamic-American Zakat Foundation and the conditions under which applications will be considered. By applying to the Islamic-American Zakat Foundation you are agreeing to the terms and conditions in this agreement.

The Foundation will, within the limited resources available to it, and subject to its policies and the discretion of the Review Committee, attempt to assist applicants seeking zakat and/or sadaqa. It is our hope to address not only short-term financial needs, but chronic needs that may underlie financial needs. Accordingly, any applicant may be required to participate in the MEDINA program in order to qualify for assistance. In areas where the MEDINA program is offered, applicants for repeat assistance are automatically applicants for participation in the MEDINA program. The MEDINA program aims to personalize client relationships with the Foundation through the assignment of an "Ansar" who will meet with the client, at least by telephone and possibly in person, to assess and evaluate client needs. The Ansar will be the client’s link to the Review Committee. The Ansar, normally a volunteer, has been trained in the Zakat Foundation procedures and provided with a resource manual, and will seek to establish a brotherly relationship with the applicant. The Ansar will be the applicant’s point of contact to the Review Committee and may also be able to refer applicants to professionals and other resources.

In addition to personalizing the services of the Foundation, the MEDINA program aims at helping applicants maintain self-sufficiency. Although there may be cases where financial assistance alone is offered, the Foundation expects that in most cases additional needs such as training, referrals, and/or counseling, may be appropriate and will, when possible, seek to provide such services.

All applicants agree to cooperate with their assigned Ansar in the evaluation of their application and understand that financial assistance may be conditional on accepting training, referrals, counseling or other services which may be offered by or through the Zakat Foundation. By applying for assistance, all applicants grant consent to the Islamic-American Zakat Foundation to contact witnesses and their masjid and to perform any investigations or checks to verify, detail, or supplement information provided. The Foundation agrees to hold all information thus obtained confidential and to share them only with the Review Committee and such agents of the organization or other service agencies, including mosques local to the applicant, as may be necessary to meet the needs of the applicant.

The MEDINA program is a program in development. Applicants are expected to assist in its development and refinement by reporting directly to the Foundation’s President or Volunteer Coordinator any problems they encounter or suggestions they may have. The President or Volunteer Coordinator may be reached at the Foundation’s number 301-907-0997 or by appointment at the address above. The Foundation requires the highest standards of conduct by its volunteers and seeks a cooperative effort among its staff, consultants, volunteers and applicants in a true community of brotherhood.

Ansars and clients are encouraged to maintain a brotherly relationship outside the scope of official MEDINA program activities and contacts, but the Foundation assumes no responsibility or liability in connection with such personal relationships, even though they may further the ends of the program. In particular, the Foundation will not be liable for any claims that may arise from favors done by Ansars for applicants, such as babysitting, providing rides, or home visits when such services were not provided at the specific direction of the Foundation. Similarly, the Foundation is not liable for any claims arising from social or religious activities shared by Ansars and clients.

The Foundation will not condone any un-Islamic or illegal activities on the part of Ansars or applicants. Abusive behavior, consumption of intoxicants, and criminal activities are all cause for termination from the program. Under no circumstances should Ansars and applicants of opposite sex be alone together in a private place.

I certify that I have read the above waivers and disclosures and agree to all conditions.

_________________________________________ ____________

Applicant's signature Date