Milwaukee Islamic Da’wah Center

Financial Assistance Application

PLEASE NOTE THAT ZAKAT IS GIVEN ONCE PER 90 DAY PERIOD.

No exceptions!!

INCOMPLETE FORMS WILL NOT BE CONSIDERED.

Please bring the following documents with you to expedite your application for assistance.

1. Photo ID - 2. Rent receipt - 3. Any other bills, eviction notices, etc…

First Name

Last Name

Social Security Number

Address

Street Address

City

State

Country

Postal Code

Driver's License/State ID Number

Phone *

Email *

Date of birth

Gender

Male

Female

Reason for assistance request

Number and Age of dependents

Transportation

Own/Lease Vehicle

Public Transportation

Other

Place of Employment and Job Title

Name of Spouse

Spouse's Place of Employment and Job Title

Health Insurance

Private Insurance

Medicaid/Medicare

Uninsured