ALLEGAN HOMELESS SOLUTIONS REQUEST FOR CLIENT ASSISTANCE SHORT FORM
AHS IS THE AGENCY OF LAST RESORT. ALL OTHER AVENUES OF FUNDING MUST BE EXHASTED PRIOR TO MAKING A REQUEST OF AHS
NAME OF REFERRING AGENCY
AGENCY CONTACT PERSON
AGENCY CONTACT PHONE NUMBER
AGENCY CONTACT EMAIL
CLIENT BEING REFERRED
First Name
Last Name
CLIENT'S CONTACT INFORMATION
WHAT TYPE OF ASSISTANCE ARE YOU REQUESTING?
LICENSE PLATE TABS
CAR INSURANCE
CAR PAYMENET
RENT ASSISTANCE (Past Due, 1st Month, or Security Deposit)
UTILITY ASSISTANCE
CAMPGROUND FEE
SHORT TERM HOTEL STAY
APARTMENT APPLICATION FEE
GAS CARD - $25 increments
DRIVER'S LICENCE OR STATE ID
TENT
SLEEPING BAGS
BLANKETS
PROPANE
PERSONAL CARE ITEMS
OTHER (Explain below)
EXPLAIN CHOICE SELECTED ABOVE
(EXAMPLES: Total amount needed; Amount requested of AHS; How many of item is needed
SHARE AS MUCH AS YOU CAN ABOUT CLIENT'S SITUATION
Submit
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