NAME OF SPOUSE: ___________________________________________________
OTHER PERSONS IN HOUSEHOLD:
Name_____________________________________________Relationship_____________Age____________
Name_____________________________________________Relationship_____________Age____________
Name_____________________________________________Relationship_____________Age____________
Name_____________________________________________Relationship_____________Age____________
Name_____________________________________________Relationship_____________Age____________
SITUATION
Briefly describe reasons for
which you seek financial assistance
Net Assets (Assets less
Liabilities): $____________________________________________
Monthly Expenses on:
Accommodation: Rent $ _____________ Or Mortgage $ __________________
Medical Bills $ ________
Transportation: $ ___________________ Car/Van Payment:
_______________ Other Expenses $ ______
Have you previously applied for Assistance (zakat or non-zakat
) from the Bangladeshi-American Foundation or any other Organization? Yes ________ No
_________. If yes, give name of the organization, date(s) and amounts received:
____________________________________________________________________________________
List and attach supporting documents to verify your financial information and
situation:
____________________________________________________________________________________
Muslim Applicant: Being a Muslim, I solemnly
witness that there is no God but Allah and that Muhammad (Peace be upon him) is His
Messenger, and that the foregoing information is true to the best of my knowledge.
Non-Muslim Applicant: Being a non-Muslim, I
solemnly witness under the perjury of law that the foregoing information is true to the
best of my knowledge.
(At least two other Bangladeshi-Americans must sign this witness.)
For Muslim Witnesses: I, the undersigned, solemnly witness
that there is no God but Allah and that Muhammad (Peace be upon him) is His Messenger, and
that under the perjury of law the above information is true to the best of my
knowledge.
For Non-Muslim Witnesses: Under the perjury of law, I the
undersigned solemnly witness that the above information is true to the best of my
knowledge.
Name: ______________________________________
Address:
____________________________________
Telephone: __________________________________
E-mail: __________________________________
Signature __________________________________
Date ______________________________________
Name: _____________________________________
Address:
___________________________________
Telephone: _________________________________
E-mail: _________________________________
Signature _________________________________
Date ___________________________________
Community
Assistance Committee Decision
Names of Committee Members present at the review meeting:
____________________________________________________________________________________________________________
