Furniture Request Form : Programs : What We Do : Catholic Social Services of Southern Nebraska

Before filling out your form, please click here to review the Homeless Management Information System (HMIS) Consumers Informed Consent & Release of Information Authorization you will sign below.

Client's CSS outreach office (Required)

Client's CSS Outreach Office

This form will be forwarded to one of our Family Support Services Coordinators based on your selection above.

PLEASE NOTE:

All requests are filled on the day of scheduled delivery and are filled subject to the donations that CSS has received. Qualified requests may be granted once a year.
Please inform the client that CSS is unable to remove any furniture. For example, CSS is unable to remove worn or damaged furniture to create space for furniture provided by CSS.

About Client

Name (Required)

Client Name

Phone (Required)

Client Phone #

Email (Required)

Client Email

Social Security Number

Client Social Security Number

Date of Birth (Required)

Client Date of Birth

Client address (include apartment number)

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Client Ethnicity (Required)

Client Ethnicity

Client Race (Required)

Client Race

Client Marital Status (Required)

Client Marital status

Is the client a Veteran? (Required)

Is client a Veteran?

ASSISTANCE REQUEST DETAILS:

Please list the specific items the client needs in priority order, and include descriptions (e.g. 1- Queen bed, 2- Kitchen table and four chairs, 3-Couch –full size, 4- Coffee table). Regarding beds, please indicate which parts are needed (e.g., box springs, frame, mattress, = b, f, m). Regarding living room chairs, indicate type, e.g. upholstered, rocking, reclining, and if only that type is acceptable or if any type available would be acceptable. Similarly, describe table and lamp types, and which or if all types are acceptable.

Assistance Request Details (Required)

Reason for assistance (Required)

Why does the client need assistance?

What has kept the client from buying furniture on their own? (Required)

What has kept the client from buying furniture on their own?

LIST ALL WHO LIVE IN THE HOME (PROVIDE ALL DETAILS FOR EACH PERSON)

Person 2 info

Person 2 information

Person 3 Info

Person 3 Information

Person 4 info

Person 4 Information

Person 5 info

Person 5 Information

Person 6 info

Person 6 Information

Person 7 info

Person 7 Information

Person 8 info

Person 8 Information

Agency Referral Information

Agency Referral (Required)

Name of Agency Contact or Caseworker (Required)

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Agency Contact Phone Number (Required)

Agency Contact Email (Required)

Homeless Management Information System (HMIS) Consumers Informed Consent & Release of Information Authorization

This Release of Information will expire three years after the "date signed."

PLEASE NOTE: ALL household persons 18 and older MUST provide a digital signature in order to process your application.

Digital Signature (Required)

Type client's full legal name

Date signed

Method:

In person
Verbally

Digital Signature 2

Date Signed

Digital Signature 3

Date Signed

Digital Signature 4

Date Signed

Digital Signature 5

Date Signed

Programs