Authorisation confirmation As-Suffa Zakat authoriser name As-Suffa Zakat authoriser contact number As-Suffa Project —Please choose an option—Alimiyyah CourseHeirs of the ScholarsDiplomaLegal Advice clinicFood bankHomelessStepping StonesStreet to FeetNew RootsDA CounsellingOther If other, please specify Part 1 - About you Surname First name(s) Title —Please choose an option—MrMrsMissMs Age Date of birth Marital status Religion Nationality What is your legal status? How many years have you lived in the UK? Address including postcode How long have you been living at this property? Contact number Email address Are you currently in employment? —Please choose an option—YesNo Do you own your property? —Please choose an option—YesNo If you do not own a property, please describe your type of accommodation? E.g. council housing, housing association, private rental etc? Part 2 - About any children who live with you Child 1 Surname First name(s) Age Date of birth Gender —Please choose an option—MaleFemale Child 2 Surname First name(s) Age Date of birth Gender —Please choose an option—MaleFemale Child 3 Surname First name(s) Age Date of birth Gender —Please choose an option—MaleFemale Child 4 Surname First name(s) Age Date of birth Gender —Please choose an option—MaleFemale Part 3 - About family members and/or dependents who live with you Person 1 Surname First name(s) Date of birth Gender —Please choose an option—MaleFemale Relationship to you Are you financially responsible for them? Do they get an income (from employment, benefits etc)? Please provide details. Person 2 Surname First name(s) Date of birth Gender —Please choose an option—MaleFemale Relationship to you Are you financially responsible for them? Do they get an income (from employment, benefits etc)? Please provide details. Person 3 Surname First name(s) Date of birth Gender —Please choose an option—MaleFemale Relationship to you Are you financially responsible for them? Do they get an income (from employment, benefits etc)? Please provide details. Part 4 - Your assets Gold (in grams) Silver (in grams) Bank balance (if you have multiple accounts, provide the total of all bank accounts) Cash in hand Any other investments Property value (£) in addition to your home, including property abroad Money owed to you by any third party debtor (if anyone owes you any money please also state when it is due to be paid) Part 5 - Outstanding debt Bank overdraft Credit cards Store cards Personal debts Other (please describe) Part 6 - About your income Have you got any source of income? —Please choose an option—YesNo Please state the amount PER MONTH (figures should reflect reality of last 3 months) Employment income Self-employment income Working tax credit Child benefit Child tax credit Universal credit Employment and support allowance Housing benefit Income support Job seekers allowance Pension credit Personal independence payment Asylum/NASS support No recourse to public funds support Investment income Rental income Support from any other charities Other (please describe) Part 7 - About your expenses Please state the amount PER MONTH Rent Mortgage Gas Electricity Water rates Council tax Food Transport costs (inc. petrol/insurance if relevant) Telephone (landline)/Broadband Telephone (mobile) TV license TV satellite Loan repayment Baby/child related expenses Other (please describe) Part 8 - Have you applied to any other organisation for support? Name of organisation 1 Case number Contact person Amount of funding/support requested Name of organisation 2 Case number Contact person Amount of funding/support requested Name of organisation 3 Case number Contact person Amount of funding/support requested Part 9 - Referees Please note referees cannot be family members. It is preferred if these references are from a professional e.g. your keyworker, GP etc. Referee 1 - Name Referee 1 - Address including postcode Referee 1 - Telephone Referee 1 - Email Referee 1 - Relationship with applicant Referee 1 - Number of years known to applicant Referee 2 - Name Referee 2 - Address including postcode Referee 2 - Telephone Referee 2 - Email Referee 2 - Relationship with applicant Referee 2 - Number of years known to applicant Part 10 - Situation Please explain your situation and how you would like As-Suffa to help How did you hear about As-Suffa? Part 11 - Previous applications Have you previously applied for support from As-Suffa? —Please choose an option—NoYes If Yes, please state the date of your application and your previous application number below. Date of previous application Previous application number Please note you may only reapply on the basis of new or exceptional circumstances. Part 12 - Supporting documents Please provide proof of income by uploading your bank statements from the past 3 months Proof of ID (passport or driving license) Proof of address (at least 3 years) Any other information relevant to this application Declaration I testify in front of Allah (SWT) that the information provided on this form is true and accurate to the best of my knowledge. I testify that I am not submitting a fraudulent application and that I am genuinely in need of support. I agree that the information provided in this application will be utilised in connection with this request for Zakat. I understand that my personal information will remain private and confidential and that any sharing of information will be limited for the purposes of processing my application. I also give consent to As-Suffa to make reasonable enquiries relating to my application. Should my application be successful then I consent to As-Suffa receiving and disbursing Zakat funds on my behalf in line with its distribution framework and accompanying policies.
