Community Partnership Interest Form

Organization Information

Organization's Name *

Areas Served *Examples: Southern Maryland, NW Washington DC, entire metro DC area, etc.

Please select all that apply to the individuals you serve *Household income at or below 80 % of the Area Median Income (AMI) for their area, based on household sizeReceives public assistance such as SNAP, TANF, SSI, unemployment insurance, Summer EBT, Medicaid, or similar benefitsCurrently without a safe, stable place to live (e.g., staying in a shelter, in places not meant for living, or temporarily with others after housing loss or financial hardship)Age 62 or olderExperiencing difficulty meeting everyday necessities (housing, food, clothing, or utilities) due to a temporary crisis or unexpected eventLiving with a disability that affects one or more major life activitiesOther

Tell us a little about your organization

Contact Person's Information

Name *

Title/Role *

Phone Number *

Email Address *

Please use this space for any questions you have for us or additional information you'd like us to know0 / 180