Housing Assistance Disbursement Form
Serenity, Inc.
Date
-
Month
-
Day
Year
Date
Client Name
First Name
Last Name
Client Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client ID #
Type
STRMU
Permanent Housing
Cameron
Ryan White
Other
Reimbursable?
Yes
No
Rent Payment
Landlord
Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mail Payment to:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Monthly Rent Amount
Payment Level
100%
75%
50%
25%
Other
Funder
HOPWA
Cameron
Ryan White
Other
Check #
Check Date
-
Month
-
Day
Year
Date
Check Amount
Notes
Utility or Other Payment
Type
Utility
Other
Company
Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Account Number
Amount Due
Amount Paid
Mail Payment to:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Total Amount Owed
Payment Level
100%
75%
50%
25%
Other
Funder
HOPWA
Cameron
Ryan White
Other
Check #
Check Date
-
Month
-
Day
Year
Date
Check Amount
Notes
Entered by Staff Name
First Name
Last Name
Entered by Staff Email
example@example.com
Submit
Should be Empty: