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Please use this form to refer a participant to Amicus Fund. If accepted, the applicant(s) will be required to complete a financial literacy program either before, or simultaneous with, a financial guarantee that they can present to landlords.

Once all information below is completed, please choose the “Submit” button at the bottom of the page.

Alternatively, you can choose the “PDF” button at the bottom of the page, print and complete the application, and fax it to Amicus Fund at 914-458-5083 or e-mail it to dbirch@amicusfund.org.

CASE INFORMATION

FAMILY COMPOSITION

CURRENT STATUS

EARNED INCOME

UNEARNED INCOME

Monthly ($)

SHELTER SUPPLEMENT /SUBSIDY

OTHER DSS SERVICES

List Contact Name and Phone #

PERMANENT HOUSING READINESS

ADDITIONAL COMMENTS