Rental Home Stability Program Referral Form
To be Completed by Property Manager - Time Sensitive
CHW believes that with the stability of a good home, an inspiring goal, and powerful tools, people can change their futures. Hence, CHW’s Financial Counselors are committed to partnering with CHW residents facing financial difficulties in a pro-active effort to preserve the CHW residents’ housing and financial stability.

The Community/Property Manager initiates the program by completing the referral forms. Then the Financial Counselor along with the Head of Household meet for a personalized financial counseling session, and immediately after, the Financial Counselor provides her/his recommendations for the Regional and Asset Management Supervisors consideration.

Community Manager, please complete this form in its entirety and upload it to OnlyOffice. One copy of this completed form must be given to the resident, and one copy kept in the resident file.

It is the resident’s responsibility to contact Veronica Lagler, Financial Counselor, via email vlagler@chworks.org or at 619-282-6647 ext. 5442 or Ramon Uribe, Financial Counselor, via email ruribe@chworks.org or at 323-712-0161 to schedule a personalized financial counseling session, and to commit to work in partnership with the Financial Counselor. If the resident cancels their appointment they have 24hrs to reschedule. If Head of Household does not make an appointment and is not responsive to coach, the case will be closed.

If you are experiencing technical issues with OnlyOffice, immediately report to your supervisor and send an email to Farah Albanna at falbanna@chworks.org
RESIDENT INFORMATION
Community Name:
Resident Name(s) List all Lease Holders Adults over the age of 18:
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number
Area Code Phone Number
Cell Phone
Area Code Phone Number
Email
example@example.com
Reason for referral:
Additional Comments/Concerns
TO BE COMPLETED BY COMMUNITY/PROPERTY MANAGER
Total past due in rent:
Total due in late fees:
Total due to property:
As of date (Past due rent)
Month Day Year
Date
As of Date (Total Due in Late Fees):
Month Day Year
Date
As of Date (Total due to property):
Month Day Year
Date
Has the resident(s) listed above been late with rental payments within the past 12 months, if yes, please explain:
Has the resident(s) listed above received any lease violation notices within the past 12 months, if yes, please explain:
Community/Property Manager:
Name
First Name Last Name
Date:
Month Day Year
Date
Signature:
Clear
(CM) Email:
example@example.com
Phone Number
Area Code Phone Number
RESIDENT ACKNOWLEDGEMENT/RELEASE OF INFORMATION
By completing this form and signing below, you confirm that the information listed above is true and correct and you agree to provide the requested information, which may include personal information. CHW and its primary partner property management company respect your right to privacy and consider the information requested of you to be confidential in nature and will only release information with your permission and to those who are authorized to view this information. As part of this process you will be requested to supply documentation of all household income as well as a current copy of your credit report. As part of this process and by signing below, you acknowledge and allow CHW and ConAm to communicate and share information as it relates to the process of requesting and completing the CHW’s Housing Stability Program.
*Resident also Acknowledges that if they cancel their appointment they have 24hrs to reschedule a new appointment with the Counselor.*
Initials:
By signing and completing the information requested, I hereby authorize CHW and ConAm to release information that contains my personal information as described above.
Head of Household & Resident(s) Signatures:
Head of Household Signature:
Clear
Resident Signature:
Clear
Resident Signature:
Clear
Resident Signature
Clear
Resident Signature:
Clear
Date (Head of Household):
Month Day Year
Date
Date (Resident)
Month Day Year
Date
Date (Resident)
Month Day Year
Date
Date (Resident)
Month Day Year
Date
Should be Empty:

Rental Home Stability Program Referral Form

To be Completed by Property Manager - Time Sensitive

RESIDENT INFORMATION

TO BE COMPLETED BY COMMUNITY/PROPERTY MANAGER

Community/Property Manager:

RESIDENT ACKNOWLEDGEMENT/RELEASE OF INFORMATION