Islamic Center of Kent 20857 108 TH AVE SE Kent, WA 98031 Phone: 253-850-2260 www.islamiccenterofkent.org A. APPLICANT S INFORMATION Islamic Center of Kent (Mailing Address: P.O. Box 6339, Kent, WA 98064) Name: ID#: (Attach a copy) Address:, City, State, Zip Phone email: B. FAMILY INFORMATION # of Members (living together):, # of Member working: Total monthly household Income including social security (if any) : $ Have you applied for help from ICK before: Yes / No If yes, how many times in last one year: Briefly explain your need funding help (Attach bills/documents): I testify in front of Allah (SWT) that the above information is accurate and correctly describes the current funding needs of my family. Signature of the Applicant: Date: C. SPONSOR/REFERENCE INFORMATION Sponsor/References Name:, Phone: Address:, City, State, Zip This is to certify that the applicant is personally known to me and currently a needy family. I recommend ICK s financial help to the applicant. Signature of the Sponsor/Referee:, Date: S/L 2014- - ICK_Assistance_Form_REV_B.doc AF-2014-03 Page 1 of 6
D. FOR ICK OFFICIAL USE ONLY The Zakat/Sadaqa Distribution Committee has reviewed the application and recommends the following: 1) Approval of $ from Zakat/Sadaqa funds or 2) Rejects the application (specify reasons) Recommended by: Approved by: Team Lead, Zakat Distribution Committee President, ICK Executive Committee ICK_Assistance_Form_REV_B.doc AF-2014-03 Page 2 of 6
E. FOR ICK OFFICIAL The following list of Documents must be enclosed for financial assistance: Please provide the following to the ICK assistance shura and we will apply on your behalf. Required Documents for Assistance Program Please enclose all the following documents, without these documents application will be delayed or sometimes can not be processed. 1) Photo ID: Washington State ID for all the household members 18 years or older. 2) Housing: Lease document - all pages Subsidized housing letter if applicable e.g. Low income housing, Section 8. Mortgage statement if you are a homeowner. 3) Income: All gross income received for all household members 18 years and older during the previous 3 calendar months. Income documents may include: All Pay stubs Child support documents GAU, TANF, SSI and/or Social Security - Current award letter Unemployment - For any household member who receives Unemployment in any of the previous 3 calendar months please provide copies of the Unemployment checks. No income - For any member who did not receive income in any of the previous 3 calendar months please print and sign a copy of our No Income Declaration form and send it along with other documents. 4) Bills : Please provide previous 3 calendar months of Utility bills - Electric bill - Heating bill in case different from Electric - Mobile Phone - Water Sewer Garbage - Telephone, Internet and Cable - Any other bills (if applicable) ICK_Assistance_Form_REV_B.doc AF-2014-03 Page 3 of 6
Questions 1. Since when you have been living in Puget Sound area? 2. List down details of all the household members living with you. full name, Female/Male, Year of Birth, Relation with applicant. 3. Monthly expenses details List down your household estimated expenses per month Housing (e.g. monthly rent, mortgage payment). if you are living in subsidized house(e.g. section 8) list down your portion of rent Utilities (Electric/Gas, Water, Sewer, Garbage) Phone (cell + home phone) Cable/Internet Transportation (montly car gas or bus pass) Car payments Credit card payment Other ICK_Assistance_Form_REV_B.doc AF-2014-03 Page 4 of 6
I hereby declare under oath with Allah (ST) as my witness that: 1. Giving zakat has not been mandatory on me (zakat is not due on me) under my current financial circumstances. 2. I acknowledge that Imam has explained to me the rules of Shariah which governs the eligibility of receiving zakat. 3. I am eligible to receive zakat. Name: Signature اقسم با العظيم واشھد على ان االتي صحيح: الزكاة غير واجبه علي بسبب ظروفي الماليه الصعبه شرح لي االمام االحكام الشرعيه لمن يستحق الزكاة أنا مؤھل للحصول على الزكاة.١.٢.٣ االسم: التوقيع: ICK_Assistance_Form_REV_B.doc AF-2014-03 Page 5 of 6
Waxaan ku dhaaranayaa Allah (SW) hortiisa: 1. In aanay Zako igu waajibin, marka laga waramo xaalkayga dhaqaale. 2. In qof Imaam ama Sheekh ahi ii cadeeyey xukunka sharciga diinta ee ku saabsan ciddii u qalanta in ey Zakada qaadato. 3. Sidaas daraadeed waan u qalmaa in aan Zakada qaato. Magaca: Saxiixa: ICK_Assistance_Form_REV_B.doc AF-2014-03 Page 6 of 6