MSFS of KY Elevance Health Housing Flex Fund Request Form
For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Elevance Staff Requestor Information
Requestor First and Last Name
*
First Name
Last Name
Requestor Phone Number
Please enter a valid phone number.
Requestor Email
*
Confirmation Email
Confirmation Email - a copy of this request will be sent to this email address
Please enter a corporate email address from an approved email domain.
Member Information
Member ID Number
*
Member's Legal Name
*
First Name
Last Name
Member Phone Number
Please enter a valid phone number.
Member Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Member's Medicaid ID:
Member's Date of Birth:
*
-
Month
-
Day
Year
Date
Gender Identity
*
Please Select
Blank/Null
Female
Gender X
Male
Nonbinary
Transgender Female
Transgender Male
Other
Ethnic Origin
*
Please Select
African
African American
American Indian
Asian
Caucasian
Eastern European
Hispanic
Middle Eastern
Native American
Northern European
Russian
Western European
Not Identified
Other
County
*
Region
*
Homeless Status (Please check one)
*
At Risk of Homelessness
Experiencing Homelessness
Payment Request Details
Security Deposit
A COMPLETED IRS W-9 FORM IS REQUIRED FOR THIS ITEM
Do you have an entry for Security Deposit?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Rental Assistance
A COMPLETED IRS W-9 FORM IS REQUIRED FOR THIS ITEM
Do you have an entry for Rental Assistance?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Rental Arrears
A COMPLETED IRS W-9 FORM IS REQUIRED FOR THIS ITEM
Do you have an entry for Rental Arrears?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Utility Deposit
Do you have an entry for Utility Deposit?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Utility Arrears
Do you have an entry for Utility Arrears?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Move-In Items
Do you have an entry for Move-In Items?
Yes
Total Amount
Please utilize the Additional Expense field below for additional items purchased with a different merchant
Company/Vendor/Website
Company/Vendor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Web Links (Word Doc)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Moving Fees
A COMPLETED IRS W-9 FORM IS REQUIRED FOR THIS ITEM
Do you have an entry for Moving Fees?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Reunification Fees
Do you have an entry for Reunification Fees?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Other
Do you have an entry for Other?
Yes
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Additional Expense(s)
Do you have an entry for an Additional Expense?
Yes
Expense Category
Please Select
Move-In Items
Moving Fees (W-9 REQUIRED)
Other
Rental Arrears (W-9 REQUIRED)
Rental Assistance (W-9 REQUIRED)
Reunification Fees
Security Deposit (W-9 REQUIRED)
Utility Arrears
Utility Deposit
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Overnight Payment Option
There is an additional fee for each overnighted payment.
Overnight Payment Required?
Yes
Please Overnight The Payment For -
Security Deposit
Rental Assistance
Rental Arrears
Utility Deposit
Utility Arrears
Other
Signatures
I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Elevance Reviewer / Approving Staff Name
*
First Name
Last Name
Title
*
Elevance Approving Staff Signature
*
Elevance Staff Signature/Submission Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: