Recipient Registration "*" indicates required fields 1. Log In DetailsUsername* Password* Enter Password Confirm Password Strength indicator 2. Personal InformationFirst Name* Last Name* Email* Your Phone/Cell No.*Address* City* Zip Code* State*Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDate of Birth* MM slash DD slash YYYY Marital Status*Choose StatusSingleMarriedDivorcedWidowedHighest Level of Education*SelectHigh SchoolUndergraduatePostgraduatePhDGender*Select your genderMaleFemaleNo. of Dependents*Choose NumberNone1234more than 4Add Dependents Full Name Relationship Age Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. 3. Employment & IncomeEmployment Status*Choose StatusFull-Time EmploymentPart-Time EmploymentSelf-EmployedActively LookingUnemployedEmployer Name (Company)* Position Name* Length of Employment in years*Select no. of yearsless than 11 -2 years3-5 years5 or more yearsSupervisor Name* Supervisor Email* Supervisor Phone No.*Monthly Income in $?*4. ExpensesHousing Status*SelectPermanent Housing – Owned (No Monthly Payments)Permanent Housing – RentedPermanent Housing – MortgageTemporary HousingNo HousingRent or Mortgage /Month in $?*Total (Estimated) Utility Costs per Month?*Electricity, Gas, Water, Internet etc.Recurring Medical Expenses?*SelectYesNoIf so, how much per month?*5. AcknowledgementsPrivacy Policy* I agree to the Recipient Privacy Policy.Zakat Eligibility* I am Zakat eligible according to the Quranic definition belowZakat can be paid to deserving individuals or groups who fall into one or more of eight categories designated by God in the Quran. “Indeed, [prescribed] charitable offerings are only [to be given] to the poor and the indigent, and to those who work on [administering] it, and to those whose hearts are to be reconciled, and to [free] those in bondage, and to the debt-ridden, and for the cause of God, and to the wayfarer. [This is] an obligation from God. And God is all-knowing, all-wise.” – (Quran, 9:60)Modern Zakat Agreements* I acknowledge that Modern Zakat does not collect, manage or make any decisions for acceptance or rejection of zakat requests. I acknowledge that my zakat request(s) acceptance, rejection and zakat disbursement is dependent on the discretion and review of my case by the organization I apply to.CAPTCHANameThis field is for validation purposes and should be left unchanged.