Fillable The Quicken Loans COVID-19 Flexible Fund Request Form (Maricopa Association of Governments)

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The Quicken Loans COVID-19 Flexible Fund Request Form (Maricopa Association of Governments)

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REV. 4/28/2020
The Quicken Loans COVID-19 Flexible Fund Request Form
Instructions: To apply for COVID-19 related funds to assist your client and/or agency, print and scan this
completed form, along with any additional attachments to quickenflex@azhousingcoalition.org.
Client Information
Client
Name:
Household count:
Senior Adults (65+):
D.O.B.:
Adults (18 – 64):
SSN:
Children (17 and under):
HMIS ID:
Requesting Agency Information
Provider Agency Requesting:
Case Manager/Staff Requesting:
Case Manager/Staff Email:
Case Manager/Staff Phone:
Fund Request Information
Date of Request:
Total Amount Requesting:
Reason for Requesting:
Request available through other funding streams? Yes No
(i.e. ESG, SSVF, CDBG, CARES/CoC) Please explain avenues explored:
Other comments:
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The Quicken Loans COVID-19 Flexible Fund Request Form (Maricopa Association of Governments)

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Completed 12 August 2020

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