Section 1: Contact Information Full Name Phone Number Email Are you a: HCV Participant Authorized Representative Case Manager Other CMHA Client IDThis can be found on your voucher paperwork or previous letters from CMHA. Section 2: Unit and Contract Details Unit Adress Occupant NameHead of Household (for tenants) or Tenant Name (for landlords) The lease IS NOT signed What is the current status of the HAP contract? Section 3: Reason for Assistance What issue are you experiencing? My utilities have been shut off I received a utility disconnection notice I am defaulting on my PIPP payment My landlord has not been paid I do not know what my rent portion is I need help verifying my contract status Other I HAVE NOT contacted CMHA about this issue before When and how did you contact CMHA?When and how did you contact CMHA? Briefly describe your current situation and what you are requesting.Briefly describe your current situation and what you are requesting. Section 4: Urgency and Followup My utility service HAS NOT already been disconnected When did the disconnection occur?When did the disconnection occur? What utility is affected? Electric Gas Water Other Would you like to be contacted by phone or email (select both for either)? Upload Files Upload Files Note: only PDF and Image files are allowedNo Files Submit