Zakat Form - Zakat Network

I Acknowledge and Consent: By filling out or having the formed filled on my behalf and submitting this zakat application, I authorize the organization to verify the information contained therein. I understand I may be required to present proof of all the statements in this application upon request. I understand a representative of the organization will verify the necessary information in order to render any assistance to me in a timely and discreet manner. I am aware due to unforeseen circumstances, assistance I requested may be unavailable. When I submit this zakat application for review, I certify I have read, or had read to me all the statements in this online form and all the information given is true, correct, and complete to the best of my knowledge. If this application is approved, I authorize the zakat reviewers to pay any owed vendors directly on my behalf.

Please specifiy the organization that you would like to submit this Zakat Network application to (* required):

Applicant Information	4% Complete

Email:*

A valid email/username is required. This username/email is already registered. Login The email/username is required.

SSN:*

The social security number is required.

First Name:*

The first name is required.

Middle Name:*

The middle name is required.

Last Name:*

The last name is required.

Date of Birth:*

The date of birth is required.

Phone #:*

The phone number is required.

Gender:*

Male

Female

The gender is required.

Marital Status:*

The marital status is required.

Street:*

The address street is required.

City:*

The address city is required.

State:*

The address state is required.

Zip Code:*

The address zip code is required.

Began Living:*

The time resided at the home is required.

Home Type:*

The home type is required.

Specify:

Please specify the other home type.

Nationality:*

The nationality is required.

Citizenship:*

The citizenship status is required.

Masjid Name:*

Your primary masjid name is required.

Masjid Ph #:*

The masjid phone number is required.

Skills, Certs and Education

Languages:

Languages Spoken:*

Enter a Skill or Certification then Add to your List:

Skills and Certifications:

Highest Education Completed:*

The highest education completed is required.

International School / No School temp

School Name:*

The school name is required.

School City:*

The school city is required.

School Street:*

The school street is required.

School State:*

The school state is required.

School Zip:*

The school zip code is required.

Assets and Support	91% Complete

Cash Value:

$	Enter a valid currency amount. The cash value possessed is required.

Gold Value:

$	Enter a valid currency amount. The gold value possessed is required.

Silver Value:

$	Enter a valid currency amount. The silver value possessed is required.

Investments:

$	Enter a valid currency amount.

Retirement:

$	Enter a valid currency amount.

Are you receiving any temporary assistance?

Assistance:

$	Enter a valid currency amount.

Yes

Indicating whether you have Insurance/Medicare/Medicaid is required.

Do you have Insurance / Medicare / Medicaid?*

Life Insurance:

$	Enter a valid currency amount.

Debt Value:

$	Enter a valid currency amount. The debt value possessed is required.

Child Support:

$	Enter a valid currency amount.

Ch. Sup. Freq.:

The child support frequency is required.

Food Stamps:

$	Enter a valid currency amount.

F.S. Frequency:

The food stamp frequency is required.

Who Assisted:

The person who assisted is required.

Employment (or Previous)	11% Complete

I am not nor have been previously employed temp

Employer:*

The employer name is required.

Start Date:*

The employment start date is required.

End Date:

The employment end date is required.

Position:*

The position title is required.

Phone #:*

The employer phone number is required.

Monthly Salary:*

$	Enter a valid currency amount. The monthly salary is required.

Street:*

The address street is required.

City:*

The address city is required.

State:*

The address state is required.

Zip Code:*

The address zip code is required.

Dependent Information	0% Complete

I do not have any dependents temp

First Name:*

The first name is required.

Middle Name:*

The middle name is required.

Last Name:*

The last name is required.

Your Current List of Dependents Are Shown Below:

Date of Birth:*

The date of birth is required.

Gender:*

Male

Female

The gender is required.

Relation:*

The relatoinship is required.

You must enter your email and name before adding dependents

References 0 (2 Required)	0% Complete

First Name:*

The first name is required.

Middle Name:*

The middle name is required.

Last Name:*

The last name is required.

Relationship:*

The relationship is required.

Phone #:*

The reference phone number is required.

Your Current List of References Are Shown Below:

Known Since:*

The known since date is required.

Street:*

The address street is required.

City:*

The address city is required.

State:*

The address state is required.

Zip Code:*

The address zip code is required.

You must enter your email and name before adding references

Artifacts 0 (Gov't ID Req'd)	0% Complete

Artifact Type:*

The artifact type is required.

Your Current List of Artifacts For This Application Are Shown Below:

You must enter your email and name before uploading.

Personal Statement	0% Complete

Briefly describe your personal and/or family needs (1000 characters max):* The personal statement is required.

New Zakat Network Application

Please specifiy the organization that you would like to submit this Zakat Network application to (* required):

Applicant Information

Assets and Support

Are you receiving any temporary assistance?

Employment (or Previous)

Dependent Information

References 0 (2 Required)

Artifacts 0 (Gov't ID Req'd)

Personal Statement