Agency Referrals

If you are an MCHFH approved Referral Agency requesting household items for your client, Please complete referral form. Please note:

YOU MUST HAVE PREARRANGED TRANSPORTATION FOR THESE ITEMS. NO EXCEPTIONS !
All requests are subject to MCHFH approval and availability.

Today's Date

MM

DD

YYYY

Agency

Name of company

Name and Title of Agency respresentative

Agency Email

Email of case worker for the agency

Is this a Mid Michigan Community Action Referral

Yes

No

Agency's Representative Phone

(###)

###

####

Client's Name

Name of person in need of household items

First Name

Last Name

Household items requested

Clients will be limited to only items specifically requested and within budget set by MCHFH. This voucher expires 14 days from MCHFH approval and budget notice.

Pick up arrangment

MCHFH is not responsible for delivery. Please specify who will be responsible for transporting these items and what kind of vehicle they will be using .

Agency Referrals

Action

Info