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AIC Financial Aid Request Form
Social and Welfare at Al Noor Islamic Center
Please specify your financial needs for utilities and rent. AlNoor Islamic Center issues checks to utility or rental companies/landlord ONLY and NOT in the name of applicant. You must attach lease contract, Bills, or other statement for which this financial aid is being requested.
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* Indicates required question
First Name
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Your answer
Last Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Home Address
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Your answer
Phone Number
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Your answer
Alternative Phone Number
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Your answer
Email Address
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Your answer
Gender
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Male
Female
Driver License Number of State ID #
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Your answer
Gender
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Male
Female
Marital Status
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Single
Married
Separated
Divorced
Widowed
Number of dependents including yourself
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Your answer
Please explain if you have any permanent or temporary disability or serious illness?
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Your answer
Job Status
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Employed [part time]
Employed [Full time]
Unemployed
Self-Employed
Monthly Salary/Wages(including tips and commissions):$
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Your answer
Current or last Employer Name and address/ contact information:
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Your answer
Total monthly household income (including spouse's income, pension, social security, unemployment benefits, welfare, rental income, alimony, etc.) $
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Your answer
In the past year, have you or any of your dependents received any Financial Aid/ Assistance or is currently receiving any Financial Aid/ Assistance from any government agency/ department, any masjid or organization?
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Yes
No
The amount you received based on the previous question.
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Your answer
In last six months, have you or any of your dependents been denied or declined any Financial Aid/ Assistance Request, by any government agency/ department or any masjid or organization?
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Yes
No
Explain your financial situation:*
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Your answer
Purpose (ex. rent, gas, electricity, etc.)
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Your answer
Make checks payable to :
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Your answer
Reference 1 : Name/ Address / Contact information:
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Your answer
Relationship to Reference #1
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Your answer
Reference #2: Name/ Address / contact information:
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Your answer
Relationship to Reference #2
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Your answer
"With Allah as my witness, I declare that the information given in this Application form is true to the best of my knowledge."
Applicant's Signature / Date
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Your answer
Please attach : copy of your driver license, Lease contract, last year income tax, last 3 stub checks, or any other utility company.
Email all required documents to
welfare@alnooric.org
.
Note: Application will not processed until all required documents are submitted.
*
Yes, I will email the documents.
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