Application for Financial Aid

17%

Please fill out the form fully and attach all the required documents in order for us to process your request. Incomplete documents will not be processed and delay your request. All information will be kept strictly confidential including any documents submitted. This application can take up to 2 weeks to process after all the documentation has been received. The applicant’s signature certifies that all the information provided is true and complete.
Required Documents:

Copy of State ID or Passport
Copy of most recent Federal Income Tax Return
Copy of last 2 Pay-stubs
Copy of all Bank Account Statements (checking, savings & Investments)
Copy of Bills or other Statements for which this financial aid is being requested

Applicant’s information

Legal Full Name

First

Middle

Last

Other Name

Street Address

City

State

Zip Code

Email address

Phone Number

Age

Date of birth

Sex

Religion

Marital Status

Spouse Legal Full Name

Do you have any Kids?

How many kids do you have?

Physical Ability

Do you have any Disability?

Yes

Explain your Disability

References

Please give names and telephone numbers of two Muslim individuals in the local community (not related to you) who know about your financial difficulties, and who have not received any aid or benefits from ICM SWC in the last 2 years:

Reference 1

Reference 2

Financial Information

Applicant's Occupation

Are you Employed?

Employer's Name

Employer's Phone Number

Employer's Address

Spouse’s Occupation

Is your Spouse Employed?

Spouse Employer’s Name

Spouse Employer’s phone number

Spouse Employer’s Address

Number of dependents living with you

Total Family Income

Additional income you receive from other sources (e.g. unemployment, insurance, welfare, etc. from government and all sources)

Amount requested/Purpose/Financial Need

ICM Social and Welfare Committee processes checks to a third party. No checks will be written directly to the applicant. You must attach a lease contract, bills or other statements for which this financial aid is being requested.

Amount requested

Purpose of this request

Explain your financial situation

Upload your Bills/Statements/Contracts*

Max file size is 10mb. Allowed file extensions are jpg, jpeg, png, gif, pdf. You cannot upload more than 4 files.

Document Upload

PLEASE UPLOAD THE FOLLOWING DOCUMENTS. YOUR APPLICATION WILL BE INCOMPLETE AND CANNOT BE PROCESSED WITHOUT THESE DOCUMENTS. Please note that the below listed financial documents will be kept confidential/secured and will not be copied or reproduced.

State ID or Passport*

Max file size is 10mb. Allowed file extensions are jpg, jpeg, png, gif, pdf.

Most recent Federal Income Tax Return*

Max file size is 10mb. Allowed file extensions are jpg, jpeg, png, gif, pdf.

Last 2 Paystubs*

Max file size is 10mb. Allowed file extensions are jpg, jpeg, png, gif, pdf. You cannot upload more than 2 files

Bank Account Statements (checking, savings & Investments)*

Max file size is 10mb. Allowed file extensions are jpg, jpeg, png, gif, pdf. You cannot upload more than 4 files

Authorization

I certify that the information contained in this application is true. I authorize ICM's Social and Welfare Committee to investigate my needs and income including performing a credit check and obtaining my credit reports.

I Agree

Type your name:

Date

This field should be left blank