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8/30/13 Anoka County Family Homeless Prevention and Assistance Program (FHPAP) Direct Assistance Request Form 2013-2015 Date of Request: Agency: Agency contact person: Phone: Household Information Name of Head of Household (HH): HH DOB: Phone Number: Current address including city and zip: If requesting deposit assistance, New address: Total Household Size: # Gross income: Direct Assistance Request Select type of assistance: Prevention Homeless Assistance Rental Deposit Assistance – Copy of lease or letter from landlord is attached Rent Payment Assistance – Copy of lease or letter from landlord is attached Utility Bill Payment Assistance – Copy of utility bill is attached Transportation Costs – Agency provides proof Amount of Request: Amount Awarded: $ $ Date assistance needed: Explanation of need for assistance: (Attach additional pages as needed) Payee Information NOTE: Checks will NOT be made payable or sent directly to clients – only to vendors Make check payable to: Mailing Address: Account Number, if applicable: Agency Staff Signature Agency Authorized Signature