American Crescent Relief Zakat Application Form

ZAKAT APPLICATION FORM

To be eligible to receive zakat, the recipient must be poor and/or needy. A poor person is someone whose property, in excess of his/her basic requirements, does not reach the nisab threshold.

Instructions

Please provide accurate and detailed information so that your application can be evaluated in a timely manner.
An incomplete form WILL NOT be considered for evaluation.
The following documents can be attached to this form or emailed to info@americancrescent.org
Applicant's Photo ID (e.g. Driver’s License, State Issued ID or Passport).
Proof of income & expenses.
Other documentation that might help in the evaluation, such as medical reports, receipts, billing statements, etc.
Note that all provided documentation is considered American Crescent Relief's property and will not be returned to the applicant.
American Crescent Relief will examine all provided information and will contact the references.
Simply applying for Zakat does not mean an automatic approval of the application.
Please contact info@americancrescent.org if you have any questions or issues.

Zakat Application Form

First Name

Last Name

Email Address

Phone Number

Address

City:

State:

Zip Code:

Age:

Gender:

Driver's License / ID #:

IMPORTANT: Number of dependents living with you, including their ages and relationship to you

List all Masjids / Mosques or Organizations that you are affiliated with

Have you applied for Zakat before?

Type of Residence:

If renting, does anyone share the rent with you?

If yes, how much?

Employment Status

Why are you applying for Zakat?

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Income: Please enter '0' for amounts if not applicable.

I1. Amount earned from your Job/work

I1. Frequency

I1. Last Date Received

I2. Amount received from Social / Supplement Security Income:

I2. Frequency

I2. Last Date Received:

I3. Amount received from SNAP:

I3. Frequency

I3. Last Date Received

I4. Amount received from Subsidized/Public Housing

I4. Frequency

I4. Last Date Received

I5. Amount received from Child Support:

I5. Frequency

I5. Last Date Received

I6. Amount received from Medicaid/Medicare:

I6. Frequency

I6. Last Date Received

I7. Amount received from Alimony:

I7. Frequency

I7. Last Date Received

I8. Amount received from Unemployment:

I8. Frequency

I8. Last Date Received

I9. Amount of Zakat/Aid received from other organizations:

I9. Frequency

I9. Last Date Received

I10. Amount of any other income received:

I10. Frequency

I10. Last Date Received

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Expenses: Please enter '0' for amounts if not applicable.

E1. Amount spent on Rent:

E1. Frequency

E1. Last Payment Date

E2. Amount spent on Food:

E2. Frequency

E2. Last Payment Date

E3. Amount spent on Transportation:

E3. Frequency

E3. Last Payment Date

E4. Amount spent on Utilities/Bills:

E4. Frequency

E4. Last Payment Date

E5. Amount of any other expenses:

E5. Frequency

E5. Last Payment Date

Loan/debt amount you owe:

Due Date:

To whom you owe this amount to?:

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References:

Please provide 2 references that can confirm or verify the information provided. Muslim references are preferred.
References should not be immediate relatives or people who live with you.
References cannot be Zakat recipients.

Name of Reference 1:

Phone Number of Reference 1:

Relationship to Reference 1:

Address of Reference 1:

Name of Reference 2:

Phone Number of Reference 2:

Relationship to Reference 2:

Address of Reference 2:

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Attachments:

Copy of Photo ID

Click here to upload a copy of your Photo ID

Proof of Income & Expenses

Click here to upload proof of income & expenses

All other attachments

Click here to upload any other attachments that support your application

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Statement:

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I testify in front of Allah that the information provided is true and accurate to the best of my knowledge. I agree that the information provided will be utilized in connection with this request for Zakat.