AMSS ZAKAT ASSISTANCE APPLICATION FORM

To ensure the proper distribution of Zakat funds, every applicant must submit clear copies of the
following:
* Photo ID
*Proof of income (i.e., last pay stub)
*Other documentation that might help in the evaluation: such as medical reports, receipts,
billing statements, etc.

First Name*

Last Name*

Email*

Phone number*

Address*

Status*

Unemployed

Disabled

Social Security

Other

Total number of family members in the household*

Total Household Monthly Income $*

Average Monthly Expenses $*

Are you a patient at the AMSS Clinic?*

Medical

Dental

Both Medical and Dental

Have you applied for Zakat assistance before?*

Yes

If Yes, when? (Month/Year)

Photo ID*

Proof of Income*

Other documentation that might help in the evaluation: such as medical reports, receipts, billing statements, etc

Zakat Application form

AMSS ZAKAT ASSISTANCE APPLICATION FORM