DARUL HUDA MASJID Financial Assistance Request Form Personal Information Your Name * Date of Birth Sex Male Female Other Address Address Line 1 * Address Line 2 City State * ZIP Code * Phone Number Email Address * Type of Residence Rental Apartment Own Home Room Rental (in house) Shelter Subsidized (low income) housing other If other Financial Situation Details Current Employment Status * --Select Option-- Employed Unemployed Self-employed Student Retired Employer Name * Monthly Income (include all sources) * Monthly Expenses (e.g., Housing, food, utilities, transportation, etc.) * Do you receive any government assistance? (e.g., SNAP, Medicaid, SSI) Do you own any assets? (e.g., Home, car, savings, investments) Outstanding Debts Type (credit cards, loans, medical bills) * Outstanding Debts Ammount * Assistance Details Type of Assistance Requested * --Select Option-- Sadaqa Zakat Part-time work (e.g. Cleaning wudu area etc.) Purpose of Request (e.g., rent, medical bills, groceries, tuition) * Amount Requested * How soon do you need it? * Brief explanation of why you qualify for Zakat Have you received assistance from us before? * --Select Option-- Yes No If yes, please provide details and dates * Additional Information Reference from Masjid/Community Leader Please provide the name and contact information of a reference from our or your community who can verify your situation. Upload Your ID * Supporting Documents * Additional Information Please share any other information that might help us evaluate your request. I hereby declare that the information provided is true and accurate to the best of my knowledge. I understand that providing false information may disqualify me from receiving assistance. I consent to the collection and processing of my personal information for the purpose of evaluating this financial assistance request. Darul Huda Inc. ("Darul Huda") collects certain personal information such as name, address, phone number, e-mail, etc. to 1) determine your eligibility for assistance and level of need and 2) have updated contact information should it be necessary to reach you. Darul Huda does not share, rent or sell your personal information nor does Darul Huda exchange such information with third-parties except as necessary. Submit Please Wait…
