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Emergency Fund  - State Homeless Prevention Fund Client Service Form and Check Request

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Please submit the Client Services Info, Client File Documents, and Check Request via this form.




1. Client Information



MM/DD/YYYY format



to select multiple: control + click











2. Household Information
Include everyone else besides the client who lives in the household.
To add additional household members, click ADD ANOTHER HOUSEHOLD MEMBER at the bottom of this box.






to select multiple: control + click

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3. Program Eligibility

to select multiple: control + click

4. Coordination of Additional Services

control + click to select multiple
Case Note: Please enter the initial assesment and referral.
Example: Jane Doe was found eligible on 8/18/2023. All required documentation was submitted on 8/18/2023. In addition to the mandatory supportive services, the client was referred for the following: Child Care, Substance Abuse, and Employment Services.
Please include all referrals made.

Initial Assesment and Referrals
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5. Prevention Services

Security Deposit           Rent      Mortgage          Utility
Enter dollar amount
6. Budget

$
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Not included in total
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Narrative

Upon approval, I understand that payment will be made on my behalf for the financial assistance described in section 5.

If approved, I understand that as a part of receiving assistance I will be contacted and asked about the impact of this assistance. I agree to participate in the follow-up when contacted by the service provider.

I attest that all the information I have provided above and all of the documentation I submit to complete this application for Homeless Prevention funds is accurate and true to the best of my knowledge.

By signing my name below, I am confirming and agreeing to all the above statements.





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Housing Stability Questionnaire



Page 5 of 6


This email will receive and email confirmation with submitted data.
Check Request Invoice


$

Enter month and year range for check memo. Limit 40 characters. Example: Jun21-Jan22, Mar22







Please confirm the Vendor's PREFERRED Mailing address for the check/payment. 

Please enter the PREFERRED address in Vendor Mailing Address below.

Street, City, State, Zip

Required documents for Rental Assistance:
1. Completed W-9 form from the landlord, and
2. Current lease or ledger or Intent to Rent Letter

Required documents for Security Deposit Assistance:
1. Completed W-9 form from the landlord, and
2. Lease or Intent to rent letter

Required documents for Mortgage Assistance:
1. Mortgage statement with payment address

Required documents for Utility Assistance:
1. Copy of the entire utility bill with the head of household or household member's name, and
2. Current lease with the household member included

^^^^
ONLY CLICK IF YOU ARE GOING TO UPLOAD ANOTHER FILE. IF YOU TRY TO SUBMIT WITH "no file chosen" next to the upload link,
YOU WILL RECEIVE AN ERROR MESSAGE.
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Client File Documents
Please upload the following documents:
  1. Crisis Documents
  2. Homeless Prevention Program Documentation Checklist
  3. IDHS Supportive Services Checklist
  4. Current Income

^^^^
ONLY CLICK IF YOU ARE GOING TO UPLOAD ANOTHER FILE. IF YOU TRY TO SUBMIT WITH "no file chosen" next to the upload link,
YOU WILL RECEIVE AN ERROR MESSAGE.
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