Partnering Agencies' Client Referral Form

Rental, Utility and Emergency Shelter Assistance Referral Form

If you should have questions or comments about this form or our Partner Agency Client Referral program please contact Karina Ostenberg 702-566-0576 ext. 10

IN ADDITION: For assistance anywhere outside of the City of Henderson, clients must have children under 18 in their legal care, be disabled, or be a senior over age 60. If clients have gotten financial assistance within the past 12 months from either HopeLink or HELP of Southern Nevada, they may be ineligible. If clients have received assistance and not followed through with stated case plan, even if assistance was more than 12 months ago, they may not be eligible.

**Please be aware that upon review of above, the client may be asked to provide additional documentation.

ID’s for all the adults in the household
Social Security Cards for everyone in the household, including all children
Proof of income within the last 30 days. (Income includes check stubs, Social Security, SSI/SSDI, Child Support, TANF, Pension, etc.)
Intent to hire letter on company letterhead or other proof of future income to cover basic needs (Income must be documented and enough to cover at minimum housing, utilities and food expenses)
Copy of Lease and 5 day or 24 hour eviction notice (if applicable)
Copy of utility shut off notice
Proof of change in circumstances within the last 30 days (i.e.: proof of illness, reduction of hours, car repair, unexpected expenses)

Referring Agency:
Referring Case Manager:
Agency Phone:
Agency Fax:
Agency Contact E-mail:
Client Name:
Client Phone:
Household Size:
Service Requested:
Date:
Reason for Assistance: