NC Anthem Housing Flex Fund Request Form
Anthem Staff Requestor Information
Requestor First and Last Name
*
First Name
Last Name
Requestor Phone Number
Please enter a valid phone number.
Requestor Email
*
Confirmation Email
Confirmation Email - A copy of this submission will be sent to this email address
Member Information
Member ID Number
*
Member's First and Last Name:
*
First Name
Last Name
Member Phone Number
Please enter a valid phone number.
Member Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Member's Medicaid ID:
*
Member's Date of Birth:
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
County of Medicaid Coverage
*
Region
Homeless Status (Please check one)
*
At Risk of Homelessness
Experiencing Homelessness
Payment Request Details
Security Deposit
A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Security Deposit?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Rental Assistance
A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Rental Assistance?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Rental Arrears
A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Rental Arrears?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Utility Deposit
Do you have an entry for Utility Deposit?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Utility Arrears
Do you have an entry for Utility Arrears?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Move-In Items
Do you have an entry for Move-In Items?
Yes
Total Amount
Company/Vendor/Website
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Web Links (Word Doc)
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Moving Fees
A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Moving Fees?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Reunification Fees
Do you have an entry for Reunification Fees?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Other
Do you have an entry for Other?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Additional Expense(s)
Do you have an entry for an Additional Expense?
Yes
Expense Category
Please Select
Move-In Items
Moving Fees (W-9 REQUIRED)
Other
Rental Arrears (W-9 REQUIRED)
Rental Assistance (W-9 REQUIRED)
Reunification Fees
Security Deposit (W-9 REQUIRED)
Utility Arrears
Utility Deposit
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Additional Expense Approval
The Total Dollar Amount of This Request Is -
*
$0 - $1,000.00
$1,000.01 - $2,500.00 (Requires Manager Approval)
$2,500.01 + (Requires Director/Medical Director Approval)
Additional Approval Documentation
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Please upload a copy of the Anthem Internal Approval Form
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Anthem Reviewer / Approving Staff Name
*
First Name
Last Name
Title
*
Anthem Approving Staff Signature
*
Clear
Anthem Staff Signature/Submission Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: