Online Application for Assistance Form

Are you a resident? We regret that we'll be unable to respond to or process your request for assistance if we determine that you are not a resident of the metropolitan Seattle/Puget Sound region.

 

Please provide as much information as possible to prevent any delays in processing your application. Fields marked with an asterisk (*) are required!

 

Applicant
First Name* Middle Name Last Name*
Your Gender: Male Female
 

Spouse
First Name Middle Name Last Name
 

Contact Information

Address* City* State* Zip Code*
Phone* ( ) -
Email*
 

Children
Enter last name only if different than applicant's.
Child's Name Child's Date of Birth Child's School Child's Grade
Additional Children

Please list one per line

Citizenship
Are you a citizen of the United States? Yes No
If not, are you authorized to work in the United States? Yes No
   

Assistance History

Have you ever received assistance from Alsadaqa? Yes No

If yes, when?

 

For what purpose (explain briefly)?

Have you ever received assistance from any other organizations? Yes No
If yes, briefly explain (list oranization(s), masjid(s) when and purpose):
 

Education
Check all that apply
High School Did you graduate? Yes No Degree/Diploma
College Did you graduate? Yes No Degree/Diploma
Other Did you graduate? Yes No Degree/Diploma
         

Income Data

Employment: Unempoyment (select all that apply):
Occupation SSI
Amt: $
Company Food Stamps
Amt: $
Address TANF
Amt: $
City TANF Office
State TANF Phone
(
   ) -
Zip TANF Case Worker's Name
Salary
$
 TANF Case Number
weekly biweekly monthly    
       

Type of assistance you are seeking

Note: We process requests according to Qur'anic guidelines and available funds.
Food Clothing Rent/Mortgage/Shelter Medical Transportation
Burial Marriage Education/Tuition Utilities  

Plans for the future

Briefly explain your plan to support Alsadaqa and be self-sufficient:

References
Reference:  Relationship:  Phone Number: 
 

Amount you are requesting: $ (do not include any commas)

 

Disclaimer and Digital Signature* (required before proceeding):

I am a resident of the Puget Sound region. I understand that false or misleading information in my application may result in my application being denied and I hereby certify that my answers are true and complete to the best of my knowledge.

 

I agree to the above statement and digitally sign this document. *