Participant Name:      	
	Amount	Name of Person/Agency to be Paid	
Rent During Medical or Psychiatric Crisis 	$      	     	
		Address of Person/Agency to be Paid	
		     	

I certify that the Participant will be absent from the assisted unit due to a medical or psychiatric crisis, and that there is a high likelihood that the Participant will return to the unit within the next three months. I will keep the Housing Agency informed of the status of the Participant. 	
			
		     	
Signature of Case Manager/Housing Support Provider 	Date 	
			
Security Deposit 	$      			
Utility Deposit 	$      			

I certify that the Participant does not have the resources to pay the above deposit, and that there are no other sources of funds available to this Participant to cover these costs. 	
			
                                                                                                                                                                     	
Signature of Case Manager/Housing Support Provider 	Date	
			
                                                                                                                                                                     	
Signature of County/Agency Staff giving approval for payment (if necessary) 	Date