DISCRETIONARY FUND REQUEST FORM
Client Initials ______HMIS #:______
Client’s Telephone: ______
Requester’s Name: ______Telephone: ______
Agency: ______Date Requested: ______
Total Amount Requested $______
Reminder: this fund is intended to provide limited financial support. Requests over $500 may be approved at the discretion of Journey Home.
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FOR OFFICE USE ONLY:
Authorized: ______Date:______
Fiscal Request Notes: ______7/26/2016
*For example: Birth certificate, Connecticut Photo IDs
Hartford Residency Verification Form
This form is to verify that the person applying for assistance through Journey Home is sleeping in an emergency shelter in the City of Hartford, sleeping in a place not meant for human habitation in the City of Hartford, or is staying in an apartment in the City of Hartford. Applicants not from Hartford will be considered on a case by case basis based on the availability of alternate funds.
Applicant HMIS ID: ______Applicant Date of Birth______
Name of Person Completing the form: ______
Telephone Number of Person Completing the form: ______
OPTION 1: For applicants sleeping in an Emergency Shelter in Hartford:Name of Emergency Shelter:
Address of Emergency Shelter:
(Do not complete if at Interval House)
Town, State & Zip Code of Emergency Shelter:
ð REQUIRED: Attach Verification of the applicants shelter enrollment from the Connecticut Homeless Management Information System If staying at Interval House please attach a letter on letterhead from the shelter that states the date the applicant has been residing there.
Option 2: For applicants sleeping in a place not meant for human habitation in Hartford:
Description of Location: (example: on a bench in South Green Park)
Nearest Street Intersection: (example: near the intersection of Park St & Main St.)
ð REQUIRED: Attach Verification from the Connecticut Homeless Management Information System or a letter from an authorized Homeless Outreach Worker/Designated Soup Kitchen staff from ImmaCare, South Park Inn, Community Health Resources, Mercy Housing and Shelter, Hands On Hartford, House of Bread, Center for Children’s Advocacy, Hartford Business Improvement District, The Connection, Journey Home or Compass Youth Peacebuilders
Option 3: For applicants in an apartment in the City of Hartford:
Name on Lease
Address of Apartment or House:
Town, State & Zip Code of Apartment or House
ð REQUIRED: Attach a copy of the lease (if in the name of the applicant), or a piece of mail sent to the applicant at the above address that was received in the last three months.
*For example: Birth certificate, Connecticut Photo IDs