DVHF Flex Funding Tracker - multiple sources
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DateSurvivor ID (please use unique ID for each client)Survivor Age (drop down)Gender (drop down)Race/Ethnicity (drop down)If multiracial, and need a second race/ethnicity (drop down)Does survivor identify as an Immigrant or Refugee?Do children live with survivor? (drop down)Amount RequestedAmount Provided by DVHFDVHF Funds RemainingAmount provided by other flex fundingOther funding sourceIf funding was denied, please describe the reasons here.What were the DVHF funds used for? (drop down)Please use this space to describe what the funds were used for.What were the non-DVHF funds used for? (drop down)What other financial support or community resources did client receive? Please describe.Immediate Housing impact (drop down)If person is currently not housed, what is their situation?
Exit DateFinal Housing Impact
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EXAMPLE5/27/2016101118-24FemaleBlack/African-American/African DescentNoYes1500130098700200FFA Debt AssistancePay off rental arrears to landlord Housing prepLiterally homeless (living in car, with friends and family, etc.)
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