Furniture Assistance Referral Form

Financial Support Referral Form
Section 1 – Applicant & Household Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityGeorgia

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
Do you currently have physical access to this residence? (must have access before being referred)*

YesNo
Are you the primary applicant or case manager completing this form?*

Self (primary applicant)Case Manager/Agency Representative
If “Case Manager” is selected, Please provide the agency name, case manager name, and phone number.*
Household size*
number
Household Members*
Section 2 – Eligibility Category

When life’s challenges leave you without essential furniture, we’re here to help. Through our partnership with the Furniture Bank of Metro Atlanta, we connect individuals and families with gently used pieces so they can move forward and feel at home again. Applicants must meet at least one of the program’s eligibility categories
Do you meet the criteria? Please choose the option that best describe your current circumstances.*

I have been homeless – I now have a safe and stable place to call home.I am low-income and need furniture due to an emergency – Such as fire, bed bugs, flooding, or another event that left me without the basics.I am a survivor of domestic violence – I’m working to rebuild my home and create a fresh start.I am living with HIV/AIDS (HOPWA client)Other – Please describe: ___________
If ‘Other’ selected:“If you chose ‘Other,’ please share a few details about your situation so we can better understand your needs and how we might help.”*
Tell us more about your situation If you chose ‘Other’ or ‘Low-income and need furniture due to an emergency’, please briefly share what happened so we can understand your needs.*
Upload proof of your situation. To confirm eligibility, please upload any supporting documents you have—such as a letter from a service provider, police report, health-care documentation, or proof of emergency. Providing this will help us move your application forward quickly.

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Section 3 – Delivery & Fee Selection

Must live in one of the approved ZIP codes and be prepared to pay the delivery fee (unless you're a HOPWA clients)
Desired delivery option*

Regular Curbside Delivery – $100Regular In‑Home Delivery – $200Extended Curbside Delivery – $150Extended In‑Home Delivery – $250Fee waived (HOPWA client)
Additional Delivery Note: Furniture will be brought only to the entryway or just inside the front door of your residence — delivery teams do not move items to individual rooms. Please ensure you have assistance on delivery day if you need furniture moved beyond the threshold.*
Regular Delivery Zone*
Extended Delivery Zone*
Do you understand that all furniture is gently used and in good condition?

YesNo
Do you agree that the furniture must be delivered (no self‑pickup)?

YesNo
Section 4 – Appointment Scheduling

Ensure every question on this form is complete and all requested documents are uploaded; incomplete applications can delay your phone appointment with Up Giving Village. After submission, you’ll receive a call within 48 business hours to finalize your referral — during this appointment you must pay the delivery fee. Only after payment is received will Up Giving Village submit your referral to the Furniture Bank, so please make sure your contact information is accurate for delivery scheduling.
First preferred date for your intake appointment with Up Giving Village
Second preferred date for your intake appointment with Up Giving Village
Section 5 – Acknowledgements & Signature
Acknowledgement of Requirements
- The applicant must have access to the residence.
- All paperwork and payment must be submitted during the phone appointment with Up Giving Village before the referral is made.
- Questions should be directed to Up Giving Village rather than the Furniture Bank.
- Delivery can occur 5–6 weeks after the phone appointment with Up Giving Village.
Additional Comments/Notes
Upload Supporting Documents (Income Verification, Proof of Expenses, Identification Documents{photo id, social security card(s)} etc.)

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Consent to Share Information: I authorize Up Giving Village to share the personal information provided in this application with the Furniture Bank of Metro Atlanta for the sole purpose of arranging and delivering furniture assistance. I understand that my information will be handled confidentially and will not be used for any other purpose without my permission.

I agree to the aboveI disagree to the above. Applicants who do not grant permission should be advised that Up Giving Village will be unable to submit their referral.
Date

MonthDayYear
Date
Signature*

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Financial Support Referral Form

Section 1 – Applicant & Household Information

Section 2 – Eligibility Category

Section 3 – Delivery & Fee Selection

Section 4 – Appointment Scheduling

Section 5 – Acknowledgements & Signature