Financial Assistance Form

Application for Assistance

Before completing a Dar Al-Hijrah assistance application, please apply with the county as a first step. This will expedite your case, and help us help you.

If you are in need of assistance with rent, utilities, food, diapers or medical care, and you live in Fairfax County, please call Coordinated Services Planning (CSP) at 703-222-0880, and they can help.

If you live in Arlington, call the Arlington County Community Assistance Bureau at 703-228-1300. And if you live in the CIty of Alexandria, call the Department of Community and Human Services at 703-746-5700.

Translators are available.

Assistance is given to the most urgent cases up to one time every 24 months. If you have received assistance in the last 24 months, please call (703) 531-2905 to discuss your situation with the case manager. At the time of applying, please provide the following documents:
1. Copy of photo ID (for all adults living in the household)
2. Copy of Social Security cards OR Birth Certificates for each child in the household
3. Proof of Income (first page of most recent tax return OR 3 most recent pay stubs
4. If unemployed, please provide unemployment stubs
5. If you receive public assistance of any kind such as: TANF; SSI; Section 8; etc. Please provide relevant letter. Please your application will NOT be processed until all documents have been submitted to the social services office. Documents can be emailed to [email protected] or left in the 24 hour drop box on the Social Services porch.
Type of Assistance needed*
Please check all that apply
- Rent
- Medical
- Funeral Assistance
- Transportation
- Education
- Other
Please Specify Type of Assistance
Name*
First Middle Last
Last 4 digits of Social Security*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Gender*
- Male
- Female
Ethnicity*
- Asian
- Black and African American
- Hispanic/Latinos
- Middle Eastern and North African
- Native American
- White
- Other/Unspecified
Country of Origin*
Email Address*
Date of Birth*
MM slash DD slash YYYY
Citizenship/Visa Status*
- US Citizen
- Green Card
- Refugee
- Asylum Seeker
Phone*
Are you employed?*
- Yes
- No
Where are you employed?*
Do you have health insurance?*
What type of insurance do you have?*
Monthly Wages*
Which Masjid do you attend?*
Have you received assistance from Dar Al-Hijrah before?*
- Yes
- No
When was the assistance received*
How much was received?*
Have you previously applied for assistance from any other organization?*
- Yes
- No
When did you apply for assistance from the organization?*
How much was received?*
What is the name of the Organization?*
What is your current marital status?*
- Single
- Married
- Divorced
- Separated
- Widowed
Please enter the name of your spouse*
First Last
Last 4 digits of Spouse's Social Security Number*
Spouse's Date of Birth*
MM slash DD slash YYYY
Citizenship/Visa Status*
- US Citizen
- Green Card
- Refugee
- Asylum Seeker
Does the spouse live in the same address as you?*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Is you spouse currently employed?*
- Yes
- No
Where is the spouse currently employed?*
What is the spouse's monthly wages?*
Do you have children or anyone else living in your household?*
- Yes
- No
List all other members of the household
Name Relationship SSN Date Of Birth (mm/dd/yyyy) Age Employed (Yes/No)
Name Relationship SSN Date Of Birth (mm/dd/yyyy) Age Employed (Yes/No)
Name Relationship SSN Date Of Birth (mm/dd/yyyy) Age Employed (Yes/No)
Do you have a County caseworker?*
- Yes
- No
What is the case worker's name
First Last
Agency
Caseworker's Phone Number*
What is the amount needed?*
Please clearly explain your situation in as much detail as possible*
Monthly Gross Income*
Please enter the amount received from the source
Work (household total) Social Security Insurance TANF Food Stamps (EBT) Section 8 (housing) Child Support Charity Organization Spouse Income
Please Enter the total monthly income*
Monthly Expenses*
Please enter the amount spent on each expense
Rent/Mortgage Utilities Phone/Mobile Phone Transportation Medical Car Note / Insurance Credit Cards
Please enter the total monthly expenses*
Assets*
Please enter the amount of each asset
Checking Account Savings Account Real Estate Investments
Please enter the total value of assets*
References*
Applicants must provide two references and phone numbers
Name 1 Phone Number 1 Name 2 Phone Number 2
By typing my full name, I am agreeing to all the conditions contained in this application. 1. I understand that Dar al-Hijrah may refer my case to County Agencies and Centers first. 2. I understand that it may take a minimum of 10 days and a maximum of two weeks to process my application. 3. I understand that I can give back to the community by volunteering some of my time whenever it is convenient for me, however, I am not obligated to do so. 4. I understand that regardless of whether my application is approved or denied, I agree that Dar al-Hijrah can keep copies of my documentations, those pertaining to my file. 5. I understand that I may be subject to a home visit by a social worker. 6. Dar al-Hijrah has the right to deny any case without any explanation. 7. The social workers will collect the application information and documents to assess my current situation. They may verify the information by calling my references and/or other caseworkers, or any other institutions. 8. I acknowledge that the information that I have provided is correct. 9. Dar al-Hijrah has my permission to anonymously describe the circumstances of my case to secure funding. 10. I understand that my application will NOT be processed until after submission of all applicable documentation that is needed.* 11. By signing this application, I testify that I am not involved in any activities that would be characterized as terrorist activities. I also do not support or have any connections with individuals or organizations affiliated with terrorist activities. *Note: Please submit all the required documents to either the main office at Dar Al-Hijrah or the social services office.*
First Last

DAR AL-HIJRAH ISLAMIC CENTER
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Application for Assistance

Zakah Supplemental Application Form

Name	Relationship	SSN	Date Of Birth (mm/dd/yyyy)	Age	Employed (Yes/No)

Name	Relationship	SSN	Date Of Birth (mm/dd/yyyy)	Age	Employed (Yes/No)

Name	Relationship	SSN	Date Of Birth (mm/dd/yyyy)	Age	Employed (Yes/No)

Name 1	Phone Number 1	Name 2	Phone Number 2