Homelink Homeless Diversion Monthly Invoice Agreement
This agreement is for agencies participating in the Close To Home Homeless Diversion Pilot flex fund account who would like to directly pay for Close To Home -approved diversion assistance and be reimbursed by Close To Home on a monthly basis. This agreement will need to be signed by the 5th of each month.

Please contact ce@closetohomesa.org for questions regarding this agreement.
Sign in to Google to save your progress. Learn more
Close To Home Homeless Diversion Pilot Monthly Invoice Agreement
For the month of: *
Agency Name *
As a community partner participating in the Close To Home Homeless Diversion Pilot, I elect to pay for  Close To Home  approved diversion assistance directly.  I understand that Diversion Pilot services are not approved until my agency has been notified of approval via the Homeless Diversion Pilot Referral Status Notification. A monthly invoice must be submitted to CE@closetohomesa.org to reconcile the balance by the 5th business day of the next month.  I understand that all persons conducting Homeless Diversion Pilot assessments must have completed the  Close To Home  Diversion Problem Solving training for Diversion referrals to be approved. *
Required
First and last name of person completing this form *
Title of person completing this form *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms