CFB Furniture for Families Voucher – Cleveland Furniture Bank

Date

Partner Agency:

Caseworker Name

Caseworker phone number

Caseworker Email Address

Participating Agency Authorized By

P.O. Number

P.O. Upload

Maximum file size: 104.86MB

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 – 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

City

State/Province

Zip/Postal

Country

Phone

All appointments are done virtually. Please check which virtual meeting tool your client has access to:

Facetime

Duo

OH ID or DL #

Last 4 SSN

Furniture Needs Assessment

Please check all that apply

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