Please enable JavaScript in your browser to complete this form.Personal Information – Step 1 of 9ISCN – Zakat /Sadaqa /Fitra ApplicationPlease fill all fields. After you submit this form, email with the information you provide will be sent to head of social services. You can follow about the status of your application by contacting social services at ss@coronamuslims.com or by calling social services at (951) 523-7645.Name *FirstLastEmail *Phone *Other Phone (optional)NextMarriage Status *SingleMarriedDivorcedWidower/WidowSpouse Name *FirstLastEx-Spouse Name *FirstLastDeceased Spouse Name *FirstLastNumber of family members *1234567 or morePreviousNextAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAre you renting or own your residence? *OwnRentalPreviousNextRequested Amount *Applying for *Zakat Ul MaalSadaqaFitraThe donation I will get will be used for *RentUtilityGroceriesSchool Tuition FeeOtherPreviousNextPlease provide name, your relationship with the person, age and monthly income on each person living in the household in the paragraph below. *Please provide two personal references below. Please provide name and phone number. *PreviousNextAre you or any member of your household receiving any kind of help from Government or Non-Government organization? *YesNoIf you selected yes to above question, provide the amount you are receiving. *PreviousNextPlease check all that applies *I am over 18 years oldOnly one member of the family can apply at a time.Provided photo IDResident of Inland EmpireFile Upload Click or drag a file to this area to upload. Briefly describe the reason for your request and attach supporting documents. *PreviousNextDeclaration *Yes, I have read and accepted the termsNo, I do not consentSince you are submitting this application electronically, you the undersigned hereby declare that all the information above is true and correct to the best of your knowledge, Allah (SWT) is my witness. Disqualification *Yes, I have read and accepted the termsNo, I do not consentI also understand that any sort of false statement or misrepresentation of facts may disqualify me from any future help from ISCN.Signature Clear Signature PreviousNextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.PreviousSubmit
