To be compelted by referring professional

(Please submit application no less than 72 hours prior to discharge. A submitted application is not an approval. Any clients being sent to housing without written approval will be denied)

Will applicant be relocating to a new county or state?

Have you applied to other organizations including county or state resources for financial assistance?

Is accepting house aware intake fees/security deposits must be waived?


Have You applied to other organizations for financial assistance? If so please list below.

Do you have an specific aftercare plan? Please email a letter of commitment from client to

After Care Plan Submission

Certification that NO other financial assistance is being accepted from federal, state, county, friends, family or organizations other than the Leigh Leckerman Foundation.

4 + 12 =

*Please be advised NO funding will be granted without a completed and approved application.

The Leigh Leckerman Foundation is an emergency source of funding when ALL other resources have been denied or exhausted.