Financial Assistance | Islamic Center of Boulder

Instructions

Please provide accurate and detailed information to enable a timely and effective application evaluation.

• Note that an incomplete form will not be considered for evaluation.
• We are currently only processing applications for new applicants. We are not processing applications for those we have helped in the past.
• Applicants will be notified of the outcome via email or phone.
• Applicants can inquire about the status of the application by calling 720-340-1530 and leave a message or via email at financial-assistance@bouldermuslims.com.

Contact
Info

Circumstances

Income

Expenses

References

Statement

Step 1 — Contact Information

Email Address *

Full Name *

Date of Birth

Street Address *

City

State

ZIP Code

Phone Number *

Photo ID Upload (Driver's License, State ID, or Passport — for applicant, spouse, and dependents)

Click to upload or drag & drop
JPG, PNG, or PDF

Masjid / Islamic Organization You Visit

Step 3 — Income Assessment

Monthly Income from Job (USD)

Please specify salary amount, last date received, and how frequently you receive it

Government / Public Assistance (Food stamps/SNAP, SSI, Medicaid, child support, unemployment, subsidized housing, alimony, etc.)

Financial Aid from Other Non-Profit Organizations

Other Monthly Income (USD)

Source of Other Income

Proof of Income Upload (Pay stubs, bank statements, benefit letters, etc.)

Click to upload proof of income
PDF, DOC, JPG, or PNG

Have you received ICB assistance before?

Yes No

Step 4 — Monthly Expenses

Please provide an estimate of your monthly expenses.

Rent / Housing (per month, USD)

Food / Groceries (per month, USD)

Transportation (per month, USD)

Utilities (per month, USD)

Any Other Financial Aid Received

Loans or Debts

Additional Documentation Upload (Medical reports, receipts, billing statements, etc.)

Click to upload supporting documents
PDF, DOC, JPG, or PNG

Step 5 — References

Notice: Please note that references should not be immediate relatives or people who live with you, nor ICB Financial Assistance recipients. Please list at least 2 names of anyone with whom you are familiar and who can confirm or verify the information you provided. Muslim references are preferred, at least one, but list all references.

Reference 1

Name

Phone

Relationship

Address

Reference 2

Name

Phone

Relationship

Address

Step 6 — Statement & Submission

I testify in front of Allah SWT that the information provided on this form is true and accurate to the best of my knowledge. I agree that the information provided in this application will be utilized in connection with this request for ICB Financial Assistance.

Confidentiality: All information provided by the applicants will be held in full confidentiality.

ICB reserves the right to deny or accept part or all of this application. All decisions are made based on information verification and need, and according to the resources available at ICB. The ICB is not obligated to assist but aims to offer aid as much as possible to those in need. We attempt to help and serve everyone regardless of race, sex, gender, or religion.

Your Name (printed) *

Date

I hereby certify that all information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information may result in disqualification and that ICB reserves the right to request additional documentation.

Sunrise At: 05:42 AM

Sunset At: 08:31 PM

ICB Financial Assistance Application

Instructions

Step 1 — Contact Information

Step 2 — Applicant's Circumstances

Step 3 — Income Assessment

Step 4 — Monthly Expenses

Step 5 — References

Step 6 — Statement & Submission

Phone no:

Email Address: