Fulton County Extended Stay Hotel Grant

The Fulton County Extended Stay Hotel grant was awarded to SVdP Georgia to assist our clients with their extended stay bills in Fulton County.

This is a reimbursement grant and you are required to submit appropriate documentation. The reimbursement will be for assistance provided from March 17, 2021 to December 31, 2021, or until funds are exhausted.

"*" indicates required fields

Conference/Caseworker Information

Name of Person Submitting Request*

First Last

Email*

District*

Conference*

CMS Case #*

Client Information

Client Name*

First Last

Date of Birth*

Gender*

Race*

Ethnicity*

Number of people in household (including client)*

Name of Extended Stay Hotel*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Amount to be paid*

Date Assistance Was Provided*

Upload Copy of Bill

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Accepted file formats: jpg, gif, png, pdf

PLEASE CHECK THIS BOX TO CONFIRM THAT PAYMENT FOR THIS BILL HAS NOT BEEN DUPLICATED:*

I CONFIRM THAT THIS ARPA ASSISTANCE DOES NOT DUPLICATE ANY OTHER ASSISTANCE FOR THE SAME COST.

Fulton County Extended Stay Hotel Grant

Fulton County Extended Stay Hotel Grant

Conference/Caseworker Information

Client Information

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