Fillable New York State Department of Health NHTD/TBI Housing (New York State)

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New York State Department of Health NHTD/TBI Housing (New York State)

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Attachment #6
New York State Department of Health
NHTD/TBI Housing Program
Housing Support Addendum: Household Goods- Actual Expenditures
P
articipant _________________________________________________________ Date ______________________
Service Coordination Agency _________________________________________ Phone _____________________
Service Coordinator _________________________________________________
P
lease attach all receipts for household goods purchased.
T
he participant has purchased the following household goods:
ITEM
AMOUNT
Kitchen Items (dishes, pots/pans, silverware, appliances, etc.)
Total
Bedroom Items (bed, chest of drawers, linens, etc.)
Total
Living Room Items (chair, coffee table, television, etc.)
Total
Bathroom Items (rugs, accessories, shower curtain, etc.)
Total
Laundry/Cleaning Supplies (iron, laundry basket, cleaning utensils, etc.)
Total
Accessories/Other (clocks, lamps, light bulbs, first aid kit, etc.)
Total
TOTAL FOR ALL ITEMS PURCHASED
T
he items listed above have been purchased on behalf of the participant and are in his/her possession.
S
ervice Coordinator Signature ______________________________________________________________________
0
0
0
0
0
0
0
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New York State Department of Health NHTDTBI Housing (New York State)

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Completed 14 August 2020

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