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.
Requesting Agency Information
Provider Agency Requesting:
Case Manager/Staff Requesting:
Case Manager/Staff Email:
Case Manager/Staff Phone:
Food - Food Delivery/Groceries
Basic Needs - Hygiene/Basic Needs
Basic Needs – Medical supplies (PPE, etc)
Basic Needs – COVID diagnostic test or anti-body test
Transportation - Transportation to Emergency Services
Transportation - Transportation to Q&I Hotel/Motel
Housing - Emergency placement for Q&I Hotel/Motel
Housing – HQS Inspections
Housing - Security/Rental Deposit
Housing - Eviction Prevention available after July 1, 2020
Request available through other funding streams? Yes No
(i.e. ESG, SSVF, CDBG, CARES/CoC) Please explain avenues explored: