Afalah Ramadhan | Social Aid Recipient Registration

ID EN

Social Aid Recipient Registration

Masjid Al Falah Bassura City

Assalamu'alaikum, this form is used to register residents who need social assistance from the mosque. The data you fill in will be verified by the mosque team.

1Personal Data

2Area

3Guardian

4Documents

Have You Received Zakat / Qurban Before?

If you have been registered as a zakat or qurban recipient, search by name or phone number to auto-fill the data.

Recipient Personal Data

Fill in data according to official identity (ID Card/Birth Certificate). Make sure the phone number is active as it will be used for confirmation.

Full Name

Gender

Male

Female

Date of Birth

Phone / WhatsApp

Recipient Category

Select one or more categories that match the recipient's condition.

Orphan (Father)

Orphan (Both Parents)

Elderly

Underprivileged

Widow

Disability

Chronic Illness

Domicile Area

Select the recipient's residential area in order: Province, Regency/City, District, then Village/Sub-district.

Province

Regency / City

District

Village / Sub-district

Guardian / Responsible Person

Guardian is the person responsible for the aid recipient. Can be a parent, sibling, or responsible party.

Guardian Name

Guardian Phone

Relationship with Recipient

Upload Documents

Upload supporting documents if available. Format: PDF, JPG, or PNG. Maximum 5MB per file. Documents can be completed later during verification by the mosque team.

Birth Certificate Optional

Scan or photo of the recipient's birth certificate

Family Card (KK)

Scan or photo of the valid family card

Parent / Guardian ID Card

Scan or photo of the guardian's ID card

Additional Notes Optional

All complete? Make sure all data is correct before submitting.