To access your existing application, please click here
To access your existing 2024 application, please click here
To access the 2024 Patient Treatment Verification form, please click here
Para recibir asistencia en español, haga clic aquí
I am prepared to complete an online application for assistance and provide all required documents.
Estoy preparado para completar una solicitud en línea de asistencia y proporcionar todos los documentos requeridos.
Effective August 1, 2024, patients will be eligible to receive financial assistance for a maximum of two fiscal years (January-December) starting from the first approval date.
# of People in the Home | Monthly Income | Annual Income |
---|---|---|
1 | $2,510 | $30,120 |
2 | $3,407 | $40,880 |
3 | $4,303 | $51,640 |
4 | $5,200 | $62,400 |
5 | $6,097 | $73,160 |
6 | $6,993 | $83,920 |
7 | $7,890 | $94,680 |
8 | $8,787 | $105,440 |
Each Additional | $897 | $10,760 |
The types of bills that can be paid include:
If you share bills with an individual who is not a part of your household, FCSF may pay your share.
*Rent requires lease and W9 for payment: If you are submitting a lease for us to pay rent in 2024, we require a W-9 form to be completed by your landlord or property management company. Due to IRS guidelines, the W-9 must be dated within the 2024 calendar year between 1/1/2024 and 12/31/2024. We also verify information reported with the IRS. We are unable to accept a W-9 dated prior to 2024.
All grants are paid by check and mailed directly to the entity, landlord or company and NOT to the patient. Please allow time for the mail to arrive.
Bills will not be required until an application is approved.
To submit your documents you can:
If you don’t have access to email or fax, you may bring your documents to your doctor’s office and have them fax or email them to us.
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