Emergency Housing Request
Please fill out the following form along with standard Ryan White Client Intake Form and attach all necessary supporting
documentation. Failure to submit a complete application and required documentation may result in request being denied
and returned to applying case manager.
I. Client Information Household Income: _____________________________
# of Adults:________ Age(s) and Sex:______________ # of Children:______ Age(s) and Sex:__________________
II. Is the applicant currently receiving, on a waiting list or been denied for other forms of housing assistance
(indicate date or N/A)?
Receiving (Date) Waiting List (Date) Ineligible (Date)
Supportive Housing/Section 8/Other _________________ _________________ _________________
Has the person called 211 and received a date for an intake through the Coordinated Access Network (CAN)?
Yes No
If the person is not currently receiving a subsidy or on a waiting list for other housing assistance, explain why:
Clearly describe the reason for emergency need:
III. Attach all of the following information. Applications without complete documentation will be denied.
Verification of income for all members of household.
Documentation to support request (if applicable).
Signatures: client signatures on release form, application form (below); case manager and supervisor signatures
on application form (next page).
I acknowledge that all information contained in this application is true and correct to the best of my knowledge. I
authorize my case manager to discuss the information contained in this application with representatives of the Housing
Assistance Fund. I also promise to immediately inform my case manager of any and all changes to my income or housing
status.
Client Name (please print): ___________________________________________________________________________
Client Signature : _______________________________________________________ Date: _____________________
Case Manager Name (please print): _____________________________________________________________________
Case Manager Signature: _________________________________________________ Date: _____________________
Agency: ____________________________________ Phone: __________________ Fax: ______________________
Address: __________________________________________________________________________________________
Supervisor's Signature: __________________________________________________ Date: _____________________
Last Updated 6/19
