CFB Furniture For Families Voucher Date * Partner Agency: * Caseworker Name * Caseworker phone number * Caseworker Email Address * Participating Agency Authorized By P.O. Number P.O. Upload Drop a file here or click to upload Choose File Maximum file size: 516MB Total Amount Approved Payment Responsibility-Select one for each fee Agency – Pays $100 Administration Fee (non-refundable, non-transferable) * Yes No Agency – If Split Payment indicate Amount for Administration Fee (non-refundable, non-transferable) Client Needs to pay this portion of Administration Fee before Scheduling appointment Agency – Pays $80 Curbside Delivery Fee (non-transferable) * Yes No Agency – The Beds for Kids Bed is $150. Agency and or cients will be responsible for paying for each one of these selected. * Yes No Agency – The Beds for Kids Crib is $195. Agency and or cients will be responsible for paying for each one of these selected. * Yes No Agency – If Split Payment indicate Amount for Curbside Delivery Fee (non-transferable) Client Needs to pay this portion of Curbside Delivery Fee before Scheduling appointment Client Info Client/ID Holder’s Name * Child’s Name Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone * All appointments are done virtually. Please check which virtual meeting tool your client has access to: * Facetime Duo WhatsApp OH ID or DL # * Last 4 SSN * Furniture Needs Assessment Please check all that apply * Adult Mattress Set-Client’s bed Couch or Loveseat Living Room Chair Dresser Kitchen Table Kitchen Chairs (4) Child’s bed (age 2-17) Child’s bed (age 2-17) Crib (age 2 and under) Please do not list items that the client already owns. Items provided, are USED and from the “Furniture for Families” Show Room. Children’s beds are brand new. All Items are Subject to Availability. Child Bed 1 – Date of Birth of Child Child Bed 2 – Date of Birth of Child Crib 1 – Date of Birth of Child “Beds for Kids” requests, will be honored for the custodial parents or legal guardians- with valid proof. For example guardianship benefits. If the client receives SNAP benefits, the client can provide Proof of Eligibility Award Letter. Client’s name must appear on the Birth Certificates, which are required at the appointment. Additional Comments Submit If you are human, leave this field blank. Δ
