Application for Assistance — The Foundation for Local Needy

Welcome

إِنَّمَا الصَّدَقَاتُ لِلْفُقَرَاءِ وَالْمَسَاكِينِ

"Charity is only for the poor and the needy…" — Qur'an 9:60

This application helps us understand your situation so we can provide meaningful, quality support. It takes about 15–20 minutes. Please have your identification, proof of income, and relevant bills ready to upload in Section 7.

You can move back and forth between sections with the buttons at the bottom. Please answer accurately and truthfully.

Data Use & Privacy Authorization

By signing below, I voluntarily authorize The Foundation for Local Needy ("the Organization") to collect, store, use, and share my personal information solely for the purpose of evaluating and processing my request for charitable assistance.

1. Information Collected. This may include government-issued ID, Social Security Numbers, financial records, medical bills, eviction notices, and other documents relevant to my application, for myself and immediate family members. * 2. Sharing With Third Parties. I authorize the Organization to share relevant information — on a need-to-know basis only — with partner charitable organizations, mosques, and community members to verify my application and coordinate assistance. * 3. Confidentiality & Security. The Organization will treat my information as strictly confidential. All volunteers and staff are prohibited from discussing it beyond operational necessity. Reasonable security measures will be applied to protect against unauthorized access. * 4. Limitation of Liability. I release the Organization, its officers, volunteers, and contractors from liability for any unintentional data breach or unauthorized disclosure, to the extent permitted by applicable law, including the NJ Identity Theft Prevention Act and NJ Data Breach Notification Law. * 5. No Guarantee of Assistance. Signing this agreement does not guarantee I will receive assistance; it only authorizes collection and use of my information as described above. *

Please tick all five items to continue.

Section 1 — Application Instructions & Agreement

Assistance is offered to eligible individuals and families. Providing complete and truthful information, along with the required supporting documents, allows us to process your request without delay.

Yes, I agree to complete this application accurately and provide the required supporting documents. *

You must agree to continue.

Section 2 — Applicant Personal Information

Full Legal Name *

Please enter your full legal name.

Date of Birth *

Please enter a date of birth in the past.

Gender *

Male Female

Please select one.

Mailing Address — Street *

Required.

Street Address Line 2

City *

Required.

State *

Use the 2-letter code (NJ, NY, PA…).

Required.

ZIP Code *

Required.

Primary Phone Number *

Required.

Email Address *

Please enter a valid email.

Marital Status *

Required.

Legal Status *

Required.

Legal Status — please specify *

Please specify your legal status.

Housing Type *

Own Home Apartment / Rental Shelter

Please select one.

Section 3 — Community Member Details

Your referral source cannot be a friend or relative. It must be an Imam or an official from your local Masjid.

Referrer Name *

Required.

Title / Role *

Required.

Masjid Name *

Required.

Referrer Phone *

Required.

Referrer Email

Section 4 — Employment History

Employment Status *

Employed Unemployed

Please select one.

Employer Details *

Company name, manager & phone, your position, and wage/salary.

Required.

Section 5 — Household Dependents

Household Dependents *

One row per person. A new row appears as you fill the last one.

NameGenderAge Relationship

I have no dependents

Please list each dependent, or tick “I have no dependents”.

Total Household Size *

Total number of people living in your household, including yourself.

Required.

Section 6 — Explanation of Financial Need

Explanation of Hardship / Financial Need *

Required.

Monthly Income — Breakdown *

Required.

Total Monthly Income ($) *

Required.

Monthly Expenses — Breakdown *

Required.

Total Monthly Expenses ($) *

Required.

Requested Assistance Type *

Required.

Requested Assistance Amount ($) *

Required.

Have you received Zakat/Sadaqah elsewhere in the past 6 months? *

Yes No

Please select one.

Which organization? *

Please name the organization.

Have you applied to / received assistance from the Foundation before? *

Yes No

Please select one.

Has anyone in your household applied before? *

Yes No

Please select one.

Section 7 — Document Uploads

Accepted: PDF, JPG, PNG, HEIC, DOC, DOCX. You may attach multiple files per item (max ~25 MB each).

Photo ID *

Driver's licence, State ID, or passport.

At least one file is required.

Social Security Card copy *

A clear photo or scan of the card, with the number readable.

At least one file is required.

Proof of Income / Unemployment *

Pay stubs, most recent 1040, SSD/SSI letters, etc.

At least one file is required.

Unpaid Bills, Lease / Mortgage, or Denial Letters *

At least one file is required.

The following are optional — attach only if applicable:

SSD / SSI / VA / Pension documentation

Unemployment benefits (approval letter / statement)

SNAP / rental-assistance approval or denial letters

Out-of-NJ Masjid reference letter (Imam / President / Board) *

Required because your address is outside New Jersey.

Required for applicants residing outside NJ.

Section 8 — Declaration & Signature

وَاللَّهُ مَعَ الصَّابِرِينَ

"…and Allah is with those who are patient." — Qur'an 8:46 (cf. 9:119)

I declare that the information provided in this application is true and complete to the best of my knowledge. I understand that any misrepresentation may result in the denial of assistance.

Type your Full Legal Name *

Please type your full legal name.

Signature *

Sign in the box below using your mouse or finger.

A signature is required.

Submission date and time are recorded automatically.