dar al hijrah islamic center word - zakat-ul-fitr application 2016.doc created date 5/30/2016...
TRANSCRIPT
OFFICE USE ONLY Received: _______/20 Decision: [ ] Approved [ ] Differ [ ] Denied Amount Approved:________
[ ] New [ ] Repeat Date__________/20 Initials:________ __________ _________ Notes:_____________________________________________________________________________________
Dar Al-Hijrah Islamic Center 3159 Row Street, Falls Church, VA 22044/ phone (703)531-2905 [email protected]
ZAKAT-UL-FITR APPLICATION
The following items are REQUIRED in order to process your application: • Write clearly in CAPITAL letters. All portions of the form must be completed; INCOMPLETE
APPLICATIONS MAYBE DELAYED OR DENIED • Attach a copy of picture IDs and copy of Social Security cards. And income verification documents (for all persons
in household). Note: IDs must match current address. • Deadline for submitting application is July 1, 2016.
Today’s date:_______________ Social Security#:________________ Phone #: - - Name (Head of Household):___________________________________________________________ First Name Last Name Middle Initial Address: __________________________________________________________________________ City: ________________________________ State: ________ Zip Code: _____________ Marital Status (check one):___Married ___Single ____Divorced ____Widowed __ Separated Legal Status: [ ] US Citizen [ ] Legal Resident (Green Card) [ ] Visa type ______________ TOTAL NUMBER OF FAMILY MEMBERS RESIDING IN HOUSEHOLD:___________________
Child(1) Name:________________________ Date of Birth_____________ Relationship:________ Child(2) Name:________________________ Date of Birth____________ Relationship:_________
Child(3) Name:________________________ Date of Birth_____________ Relationship:_________ [For more space to list more names, please use the backside of this page] OTHER PERSONS IN HOUSEHOLD
(1) Name: _____________________________ Date of Birth_____________ Relationship__________ (2) Name: _____________________________ Date of Birth_____________ Relationship__________ MONTHLY INCOME OF ALL PERSONS IN HOUSEHOLD: $_________________________ Government Assistance: $_________________ Private Institution Assistance: $_______________
TOTAL MONTHLY EXPENSES Rent:_______ Utilities (bills):________ Food:_______ Medical:______ Transportation:______ Please read and sign below: I, ___________________________, acknowledge that the information above is correct to the best of my knowledge. By submitting this application, I also affirm myself (and my household) to be eligible for Zakatul Fitr.
APPLICANT SIGNATURE______________________________ DATE______/______/_______