Housing Stabilization Intake and Referral Form

For security deposit & first months rent assistance only
First months rent assistance requested:
Security deposit amount requested:
Address of where you plan to move:
Please detail below who you have already reached out to for assistance, and the current status of that request.
I have contacted the following agency for assistance: agency name
The outcome of this is/was: outcome
I have contacted the following agency for assistance: agency name
The outcome of this is/was: outcome

For utility assistance only
# of months owed on utilities
Amount requested for utilities
Name of Utility Company
Account number
Utility Company Phone Number
Please detail below who you have already reached out to for assistance, and the current status of that request.
I have contacted the following agency for assistance: agency name
The outcome of this is/was: outcome
I have contacted the following agency for assistance: agency name
The outcome of this is/was: outcome

Contacts & References
If I need a reference, I know these people will give me one:
Contact name:   First Name   Last Name
Phone number:   Phone number
How they know me:   Relationship
Contact name:   First Name   Last Name
Phone number:   Phone number
How they know me:   Relationship
Contact name:   First Name   Last Name
Phone number:   Phone number
How they know me:   Relationship

Non Disclosure Agreement
I First Name Last Name , give permission to Affinity Residential Care LLC to disclose information given on this intake form above.

I understand that these forms will be used to coordinate with different service organizations.

I hereby give permission to disclose any of the above information. I have read this release before signing below, and I fully understand the contents, meaning and impact of this non disclosure agreement
Todays date:

MonthDayYear
Date
Signature

Clear
Should be Empty:

Housing Stabilization Intake & Referral Form