(‫ ﺘﺠدﯿد‬/‫ﻋﺎﺠل‬/‫اﺴﺘﻤﺎرة طﻠب ﻤﺴﺎﻋدة )ﺠدﯿد ﻋﺎدي‬

The Application Form for Receiving an Aid (new normal / urgent / renew)

File No / ‫رﻗم اﻟﻤﻠف‬ Date Of Application / ‫ﺘﺎرﯿﺦ اﻟﺘﻘدﯿم‬

‫ ﺒﯿﺎﻨﺎت اﻟﻤﻠف‬/ File Data
No / ‫ ﻻ‬ - Yes / ‫ ﻨﻌم‬ Have you applied for a financial aid from Zakat Fund before? ‫ﻫل ﺴﺒق ﻟك اﻟﺘﻘدﯿم ﻓﻲ ﺼﻨدوق اﻟزﻛﺎة؟‬
No / ‫ ﻻ‬ -Yes / ‫ ﻨﻌم‬ Have you applied for a financial aid from another institution before? ‫ﻫل ﺴﺒق ﻟك اﻟﺘﻘدﯿم ﻓﻲ ﺠﻬﺎت أﺨرى؟‬
UAEU ID: ‫ اﻟﺒﯿﺎﻨﺎت اﻟﺸﺨﺼﯿﺔ‬/ Personal Data
Nationality / ‫اﻟﺠﻨﺴﯿ ـ ـ ـ ـﺔ‬ Name / ‫اﻻﺴ ــم‬
‫ﻋـدد أﻓ ـراد اﻷﺴـرة‬
Social State / ‫اﻟﺤﺎﻟﺔ اﻻﺠﺘﻤﺎﻋﯿﺔ‬
Number of Family Members
Religion / ‫اﻟدﯿـ ــﺎﻨﺔ‬ Date of Birth / ‫ﺘـﺎرﯿﺦ اﻟﻤﯿﻼد‬

Employer / ‫ﺠﻬﺔ اﻟﻌﻤل‬ Job / ‫اﻟﻤﻬﻨﺔ‬

‫ اﻟﻬوﯿﺔ‬/ ‫رﻗم اﻟﺠواز‬
Monthly Income / ‫اﻟدﺨل اﻟﺸﻬري‬
Number of Passport /ID
‫رﻗم ﻫﺎﺘف ﺒدﯿل‬
Telephone No. / ‫رﻗم اﻟﻬﺎﺘف‬
Alternate Tel. No
No / ‫ ﻻ‬ -Yes / ‫ ﻨﻌم‬ Is there a family member with special needs? ‫ﻫل أﺤد ﻤن أﻓراد اﻷﺴرة ﻤﻌﺎق؟‬
‫ ﺒﯿﺎﻨﺎت اﻟﺴﻛن‬/ Housing data
Area / ‫اﻟﻤﻨطﻘﺔ‬ City / ‫اﻟﻤدﯿﻨﺔ‬ Emirate / ‫اﻹﻤ ـ ـ ـ ــﺎرة‬
Accommodation (Leased/owned/…../‫ﻤﻠك‬/‫ﻨوع اﻟﺴﻛن )إﯿﺠﺎر‬
What is the purpose of providing assistance?‫ﻤﺎ ﻫو اﻟﻐرض ﻤن ﺘﻘدﯿم اﻟﻤﺴﺎﻋدة؟‬
/ ‫ ﻤﺎﻟﯿﺔ‬
✔ / ‫ طﻠﺒﺔ ﻤدارس‬ / ‫ ﺘﻛﻠﻔﺔ ﻋﻼﺠﯿﺔ‬
Case / ‫ ﻗﻀﯿﺔ‬ Other / ‫ أﺨرى‬
Financial Schools Sstudents The cost of treatment
Pledge and authorization ratification / ‫اﻗرار وﺘﻌﻬد وﺘﺨوﯿل‬
،‫ و أﺘﻌﻬد أن أﺘﺤﻤل ﻛﺎﻤل اﻟﻤﺴؤوﻟﯿﺔ اﻟﻘﺎﻨوﻨﯿﺔ ﺤﺎل ﺜﺒوت ﻋدم ﺼـﺤﺘﻬﺎ أو ﺒﻌض ﻤﻨﻬﺎ‬،‫أﻗر أﻨﺎ اﻟﻤوﻗﻊ أدﻨﺎﻩ ﺒﺼـﺤﺔ ﺠﻤﯿﻊ اﻟﻤﺴﺘﻨدات اﻟﺘـﻲ ﺘم ﺘﻘدﯿﻤﻬﺎ و اﻟـﺘﻲ ﺘﺜﺒت ﺤﺎﺠﺘﻲ ﻟﻠﻤﺴﺎﻋدة‬
‫ وﻟﻠﻤؤﺴﺴﺔ )ﺼﻨدوق اﻟزﻛﺎة( اﻟﺤق ﺒﺈﺘﺨﺎذ ﻤﺎ ﺘراﻩ ﻤﻨﺎﺴﺒﺎً وﻓق ﻟواﺌﺤﻬﺎ اﻟداﺨﻠﯿﺔ و‬،‫و أن ﻛل ﻤﺎ ذﻛرﺘﻪ ﻓﻲ طﻠب اﻟﻤﺴﺎﻋدة اﻟزﻛوﯿﺔ ﺼـﺤﯿﺢ و ﻟم أُﺨﻔﻲ ﺸﻲء ﻋن ﺼﻨدوق اﻟزﻛﺎة‬
‫ ﻛﻤﺎ أﺘﻌﻬد ﺒﻌدم اﻟﻤطﺎﻟﺒﺔ ﺒﺄي ﻤن‬.‫ُﺨول ﺼﻨدوق اﻟزﻛﺎة ﺒﺎﻟﺒﺤث و اﻟﺘﺤري ﻋن ﻛﺎﻓﺔ ﻤﺎ ﺘراﻩ ﻤﻨﺎﺴﺒﺎً ﻹﺴﺘﻛﻤﺎل اﻟﺜﺒوﺘﯿﺎت اﻟﻼزﻤﺔ ﻟﻠطﻠب‬ ّ ‫ وأ‬.‫اﻹﺠ ارءات اﻟﻘﺎﻨوﻨﯿﺔ إن ﺜﺒت ﺨﻼف ذﻟك‬
.‫ وﻻ ﻤﺎﻨﻊ ﻟدي ﻤن ﻋﻤل زﯿﺎرة ﻤﯿداﻨﯿﺔ ﻟﻤﻘر اﻟﺴﻛن اﻟﺨﺎص ﺒﻲ ﻤن ﻗﺒﻠﻛم‬،‫اﻷوراق اﻟﺜﺒوﺘﯿﺔ اﻟﺘﻲ ﺘﻘدﻤت ﺒﻬﺎ ﻟﺼﻨدوق اﻟزﻛﺎة ﺒﻐرض اﻟﺘﺴﺠﯿ ــل ﺴـ ـواء ﻗﺒل اﻟطﻠب أم رﻓض‬
I am the undersigned and I confirm the validity of all the submitted required documents that a prove my needy. I am committed to take the legal responsibility if these documents or
some of them are incorrect. I confirm that I endorsed everything I have said about my circumstances and I didn’t miss to mention for “zakat fund” any important point. Zakat fund
has the right to take the action in accordance with its internal regulations and legal procedures if it is prove otherwise. I enable zakat fund to search and investigate in all that it
deems necessary to complete the important documents. I am committed that I will not request for any of these identification documents which I submitted to zakat fund for
registration whether my application had been approved or rejected. I give zakat fund my agreement to implement a field visit to my residence.
:Signature / ‫اﻟﺘوﻗﯿﻊ‬ :Applicant's name / ‫اﺴـم ﻤﻘدم اﻟطﻠب‬
Only for internal use ‫ﻟﻼﺴﺘﻌﻤﺎل اﻟداﺨﻠﻲ ﻓﻘط‬
(‫اﺴم اﻟﻤﺸروع)ﺤﺴب رﻏﺒﺔ اﻟﻤﺘﻌﺎﻤل‬
‫ ﺘوﺠﯿﻬﺎت‬/ ‫ﻤﻼﺤظﺎت‬
‫اﺴم اﻷﺨﺼﺎﺌﻲ اﻻﺠﺘﻤﺎﻋﻲ‬ ‫اﺴم ﻤوظف ﺨدﻤﺔ اﻟﻌﻤﻼء‬
‫ﺘوﻗﯿﻊ اﻷﺨﺼﺎﺌﻲ اﻻﺠﺘﻤﺎﻋﻲ‬ ‫ﺘوﻗﯿﻊ ﻤوظف ﺨدﻤﺔ اﻟﻌﻤﻼء‬

4 :‫رﻗم اﻻﺻدار‬ F-05-01-01 :‫رﻗم اﻟوﺛﯾﻘﺔ‬