TBRA Referral Form

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TBRA Referral Form

Please complete this form if you are referring an individual/household to the TBRA Program. Once you submit this form, a staff member from AHC will follow up with the individual using the contact information provided.

Name of the head of the household being Referred *

Email Address of Person you are Referring

Phone Number of Person you are Referring

Your Name (Person that is Referring) *

Your Email Address (Person that is Referring) *

Your Phone Number (Person that is Referring) *

Does this household include someone that has formerly been incarcerated?

Yes

I'm unsure

Clear selection

To the best of your ability, do you believe this household meets the income limits of the TBRA Program (refer to chart on https://www.ahcgrantcounty.com/rentalassistance)

Yes

I'm unsure

Clear selection

What is the best way to contact the person being referred? *

Through your email

Through your phone number

Through their email

Through their phone number

Other:

What is your relationship to this person?

Case Manager

Community Corrections/Probation Officer

Service Provider

Program Manager

Other:

Clear selection

What is your reason for referring this person to the TBRA Program? (Check all the apply)

They are currently incarcerated and exiting the incarceration system within 6 months

They are currently homeless or living in transitional housing

They are experiencing a housing crisis (struggling to pay their rent, being threatened with eviction, etc.

Submit

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