ISLAMIC SOCIETY OF GREATER HOUSTON
Sadqah Application

Instructions:

A. Please provide complete, detailed and specific information. Incomplete forms will not be considered.
B. Please attach the following documents with this application. You can take a photograph of the required documents and attach the photos at the end of this application:

1. Photo ID or Drivers License,
2. Social Security Card,
3. One month’s pay stubs,
4. A copy of most recent income tax return,
5. Most recent bank statement,
6. Lease copy (if applicable),
7. Rent receipt,
8. Utility or other bills (if applicable),
9. Eviction Notice (if applicable), and
10. Other documentation that will support your application

C. Please only start filling out this form when you have all required information available at your disposal. You must fill out and submit this form in one sitting since the form is not saved while you are filling it. If you loose internet connection or your session times out you will have to access and and fill out this form from scratch!

Section 1: Biographical Information

Applicant Name: *

Resident of ISGH Zone/IC: *

Address: *

City: *

State: *

Zip: *

Photo I.D. /Driver’s License#: *

Social Security#: *

Primary Phone#: *

Secondary Phone#:

Email: *

Age:

Gender:
MaleFemale

Type of Assistance Requested and reasons thereto: *

Section 2: Applicant’s Household Information

Marital Status: *
SingleMarriedDivorcedWidowed
Are you disabled:
NoYes

Total Number of Household Members: *
Adults:

Dependent Children:

Place of Residence: *
Own Home:
NoYes
Rental:
NoYes
Subsidized Housing:
NoYes
Shelter:
NoYes
Other:

Means of Transportation: *
Automobile:
NoYes
Public Transportation:
NoYes
Other:

Employment: *
Full Time:
NoYes
Part Time:
NoYes
Self Employed:
NoYes
Unemployed:

If employed, Employer Name:

If employed, Job Title:

If married, Name of Spouse:

Is spouse employed:
NoYes
If spouse employed, Employer Name:

If spouse employed, Job Title:

Section 3: Applicant’s Circumstances

Total Household Monthly Income: $

Total Household Monthly Expenses: $

Total Value of savings or other assets (cash, stocks, jewlery, etc.):$

Are you receiving financial and other assistance such as: *
(a) Food Stamps:
NoYes
(b) Social Security:
NoYes
(c) Medicare:
NoYes
(d) Temporary Needy Family Assistance:
NoYes
(e) Medicaid:
NoYes
(f) Subsidized /Public Housing:
NoYes
(g) Shelter:
NoYes
(h) Food Supplementary Program:
NoYes
(i) Alimony/Child Support:
NoYes
(j) Government Student Loans/Scholarships:
NoYes

If yes, specify Source and $ monthly amount:

Section 4: References

(List the names of persons who can substantiate the information above)

Reference #1
Name:

Phone:

Relationship:

Reference #2
Name:

Phone:

Relationship:

Applicant Signature (to be signed in-person):

Signature Date:

(acceptable file types: pdf, jpg, png)