Financial Assistance (Takaful) Application Form

Applicant Information

Name *

First

Last

SIN *

9 digits

Date of Birth *

Legal Status *

Marital Status *

Personal Information

Phone (cell/home) *

Email *

Email

Confirm Email

Home Address *

Employment information

Name of Company *

Job Title *

Company Address *

Supporting Documents

Please upload the following documents below, if applicable:

Copy of a photo ID
Last 3 paystubs (if employed)
Bank Statement (last 3 months)
Copy of Health Card
Copy of Rental/lease agreement
Letter of Explanation (Please write to us in detail, explaining your current situation and financial needs.Please specify the reason(s) you are seeking financial assistance through the Takaful program).
Information on other sources of income
Documented proof of need for special/extraordinary support (e.g., disability, medical)

File Upload

Click or drag files to this area to upload. You can upload up to 12 files.

Other request and amount

References

Reference 1 Name *

Reference 1 Phone *

Reference 2 Name

Reference 2 Phone

Applicant accepts and testifies to the following: (Please read carefully before signing)

MIA Takaful Fund Committee has permission to verify information provided by the applicant from appropriate sources.
Applicant has provided true and complete information to the best of his/her knowledge and may be disqualified for assistance if he/she knowingly provides false information on the application.
Applicant will be required to present all supporting documents, CRA filings, and/or letter of "Future Planning" upon request.
Applicant will not submit original bills or documents (Only photo copies please).
Application is accompanied by a copy of applicant's driver's license or other photo ID with current address. Incomplete applications may be declined or deferred.
MIA Takaful Fund Committee will put forth its greatest efforts to provide the best possible assistance based on individual's circumstances. Interfering factors include Zakah regulatory constraints, limited or unavailable funds. The decision made by the Takaful Committee will be final and it will not be provided in writing.
The requested assistance will be in the form of Takaful cheque, food certificates, counseling, and/ or referrals to government funded programs depending upon applicant's circumstances.
Applicant is responsible for reporting Takaful assistance to the CRA and other government agencies.
The Takaful Fund Committee may take up to 15 business days for processing and approval. (may take longer)
This application is valid for six months only, after which applicant may reapply if hardships persist.
All information and documents provided will be kept in the records for as long as the MIA Takaful Fund Committee deems necessary.
Applicant acknowledges that he/she stands before Allah (SWT) in truth and Allah (SWT) is his/her witness.

Confirmation *

I accept and testify to the above

Date