Individuals & Families Form
The information provided is used for official qualification purposes .
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By Checking the box you are consenting that all of the information provided may be collected, used, shared,
and retained for the purposes of applying for and/or receiving the Zakat and Sadaqat .
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Required
First Name  *
Last Name *
Gender *
  Address (Please include Street Name, City, Zip-code)  
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Phone Number with area code 

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Email address 
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Employment Status
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Marital Status
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Spouse first  name 
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Spouse last name 
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Is your spouse currently employed? 
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 Health Insurance
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Means of Transportation
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Type of Residence
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Please check all members living in your household. 
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Required
What is total household monthly income ? 
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Please check any of the following aid you have received within the last calendar year.
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Required
Total household monthly expenses ? (rent, grocery, utilities, phone, insurance , etc. 
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Have you received any financial assistance from  Memphis Islamic Center (MIC) ?

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Required
Have you received any financial assistance from other masjid /organization ?
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Please list two local reference with full  name and phone number . 

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Do you give permission for Zakat & Sadaqa Member to contact your references ?  *
Please describe reason(s)for which financial assistance is sought. State the reason(s)you are in need.  How this assistance from the MIC fund will meet your needs ?
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Amount requested
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I testify in front of Allah that the application information provided on this form is true and accurate to the best of my knowledge. *
Required
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