Financial Assistance Request Form
JazakAllahu Khairan for filling out this request form.

Our team is working hard to fulfill all requests in a timely manner. Please expect a response from us within the next 24-48 hours.

If this is an emergency please text (716) 589-7853
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Email *
Name *
Email *
Phone *
Date of Birth *
MM
/
DD
/
YYYY
Are you employed  *
Required
Reason you are requesting assistance: (Rent, Medical, School Fees, Vehicle (Deductible & Traffic Ticket) ,Vehicle Purchase, Utilities (Gas, Electricity etc) Groceries
*
How much amount assistance are you looking for:
Have you or any family member received assistance from RCM in the last 3 months *
I certify that all of the above information is true to the best of my knowledge (Print name below)
Please email copies of all bills to socialservices@roswellmasjid.org
A copy of your responses will be emailed to the address you provided.
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