ICOB serves the community within a 10-mile radius of Bothell, WA. Applicants outside of our community must contact their local masjids.  ICOB considers each application and decisions are made based on the evaluation and availability of funds.

NOTICE OF CONFIDENTIALIY: This Financial Assistance Form includes highly personal and confidential Information intendent only for restricted internal use by authorized personnel of ICOB exclusively for the evaluation of the Zakah requests. Unauthorized use, copy, and distribution of this information is strictly prohibited.

⏳ Please note, that the review usually takes up to a week, however, depending on the complexity of the case, it may take longer.

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– Step 1 of 3

Name *

First

Last

Name must match the name on the government ID. If you have a middle name, add it to the first name.

Address *

Address Line 1

Address Line 2

City

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Zip Code

Email *

Phone *

Citizenship Status *

• US Citizen
• Permanent Resident
• Other

Marital Status *

• Single
• Married
• Divorced
• Widowed

SSN (last four digits)

SSN (last four digits): XXX-XX-__ __ __ __

Spouse Name

Next

Financial Information

Dependents *

Number of dependents in the same household

Monthly income *

Total household monthly income

Housing situation *— Select Choice —OwnRentOther

Monthly expenses *

Total household monthly expenses

Do you have a car *— Select Choice —YesNo

Car payments

Monthly car payments (if applicable)

Are you currently employed *— Select Choice —YesNo

Total assets *

Total value of all assets including savings/stock/land/jewelry etc

Monthly Assistance *

• SSI
• Food Stamps
• Child Support
• Temporary Cash Assistance
• Other Assistance
• None of the above

Do you receive monthly assistance?

Monthly Assistance Details *

List all that apply (including the monthly amount): SSI, Food Stamps, Child Support, Temporary Cash Assistance, Other Assistance. If none of the above write “None”

Zakat *— Select Choice —YesNo

Have you received Zakah before from any organization?

Zakat Details *

Organization name, date, amount

Financial Need

Zakah Amount Being Requested *

Zakat Request Details

Please explain the reasons for requesting Zakah

Next

References and Documents

Please provide several references from the Islamic Center of Bothell community.

Community Reference

Contact Name *

First

Last

Phone *

Relationship *

Add Remove

Valid Zakat have

Valid Photo ID *

Drag & Drop Files, Choose Files to Upload

Driver’s License/State ID

Proof of Income *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

2 most recent pay stubs, disability check, SS check or proof of any other sources of income.

Bank Statements *

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.

Copies of latest bank statements (last 3 months)

Proof of Need

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Example: a letter from your landlord stating that applicant is behind the rent, copy of leases, etc. or a current utility bills, if you need help to pay your utilities

Other Evidence

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Any other evidence that shows the hardship related to what you have mentioned in your application.

Submit