• Elevance Health Behavioral Health Housing Initiative Flex Fund Request Form

  • Elevance Staff Requestor Information


  • Please enter a corporate email address from an approved email domain.

  • Member Information

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  • Security Deposit

    A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
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  • Rental Assistance

    A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
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  • Rental Arrears

    A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
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  • Utility Deposit

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  • Utility Arrears

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  • Move-In Items

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  • Moving Fees

    A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
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  • Reunification Fees

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  • Other

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  • Additional Expense(s)

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