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CCUSA-Assistance Application
How can we help you?
- Please complete the application and we will get in touch with you. We may request additional supporting documents by email.
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* Indicates required question
Email
*
Your email
Name:
*
Your answer
Phone Number:
*
Your answer
Location / Your Address: Please provide your complete address including Zip Code
*
Your answer
Why do you need assistance? - Please describe:
Your answer
What type of assistance do you need?
*
Food for needy
Family assistance
Paying bills
Iftar sponsorship
COVID-19 relief
Zakat/Fitra program
Household Items
Other:
Required
Do you have savings of the Nisab in your possession? - The gold standard is 3 ounces of gold or 87.48 grams or approximately $4,780.06.
*
Yes
No
Do you need help paying bills ? - List the bill names and amounts.
Your answer
What is you preferred method to receive payment? - Please provide Paypal ID or Zelle ID
Your answer
Please provide your State ID Number:
*
Your answer
A copy of your responses will be emailed to the address you provided.
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