Cleveland Furniture Bank Referral Form

Cleveland Furniture Bank Referral Form
Date*

MonthDayYear
Date
Caseworker Name*
Caseworker phone number*
Caseworker Email Address*
example@example.com
Client Needs to pay $100 Administration Fee and $80 Curbside Delivery Fee to CFB before Scheduling appointment. Type "Yes" to acknowledge payment responsibility.
Payable by Money Order, Credit or Debit Card (by phone) before 3pm. Fee is non-refundable, non-transferable.
Client/ID Holder’s Name
OH ID or DL #*
Last 4 SSN
"Beds for Kids" requests, will be honored for the custodial parents or legal guardians - with valid proof. Client's name must appear on the Birth Certificates, which are required at the appointment. If the client receives SNAP benefits, the client can provide Proof of Eligibility Award Letter for children they are not listed on the birth certificate for.
Child/Children's Name(s)
Child Bed 1 Date of Birth of Child

MonthDayYear
Date
Child Bed 2 Date of Birth of Child

MonthDayYear
Date
Crib 1 Date of Birth of Child

MonthDayYear
Date
Address*
City
State/Province
Zip/Postal
Phone*
All appointments are done virtually. Please check which virtual meeting tool your client would like to use:
Furniture Needs Assessment: The voucher from CFB is a one time voucher-client's cannot request future vouchers at any point. Due to this stipulation, please select all furniture items that are needed or may be needed in the future. Only caseworkers or clients may select furniture. 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.
Additional Comments
Should be Empty: