Americans Making Immigrants Safe · Application for funds

AMIS Application

Requestor

Who is completing this form and we can reach out to for any questions?

Requestor's Full Name

*

Who is filling out this request?

Your relationship to the immigrant

*

Requestor's Phone Number

*

(Whoever is filling out this form)

Requestor's email address

*

In case we have additional questions

Organization

If this referral is being submitted by an organization or agency

Immigrant Contact Information

Who will be receiving the funds?

Name

*

First Name

Last Name

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone

*

Email

*

Verify Email

*

Background/History

Country of Origin

*

Where are you from?

Alien #

If applicable

Current immigrant status

*

Undocumented

Asylum seeker

Refugee

Visa holder

Race

*

Asian

Black

Hispanic or Latino

Pacific Islander

White

Work Status of recipient

*

Legally able to work in the US

Waiting/trying to get a work permit

Unable to get a work permit

Disabled/Unable to work

Is the immigrant being detained?

If so, please indicate where.

Current living situation

*

Renting

Living with friends/family

Staying in a shelter/temporary housing

Other

How many adults in the home?

*

How many children (0-18 years) in the home?

*

Ages of All Family Members in the Home

*

Legal Representation

If you have legal representation, please list the laywer's name and contact info (we may need more information or make a payment directly to them)

Funds Request

The amount being requested

*

If the amount covers multiple costs, please list them.

Reason for the amount requested

*

Please list as much detail as possible to help us make our decision.

Beyond the requestee, will this support benefit anyone else?

*

Example: rent assistance would benefit all who live in the apartment

When do you need the funds by?

*

If you are funded we will try our best to meet your timeline but there are no guarantees.

Who should the check be made out to?

*

Phone number for the landlord or payee, in case of issues with payments:

*

Where should the check be sent to?

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Are you currently receiving any financial assistance from another organization or federal benefits?

*

If so, please briefly summarize to help the board fully understand your financial situation.

Any additional information you would like to add?

Information such as: time in the US, how many family members are here/need support, legal or other financial considerations, etc.