MSFS Elevance Health Community Connect Flex Fund Request Form

MSFS Elevance Health Community Connect Flex Fund Request Form

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Select your State*
Elevance Staff Requestor Information
Requestor First and Last Name*

First NameLast Name
Requestor Phone Number
Please enter a valid phone number.
Requestor Email*

Confirmation EmailConfirmation 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 NameLast Name
Member Phone Number
Please enter a valid phone number.
Member Address*

Street Address

Street Address Line 2

CityState

Zip Code
Member's Medicaid ID:*
Member's Date of Birth:*

MonthDayYear
Date
Gender Identity*
County of Medicaid Coverage*
Region
Homeless Status (Please check one)*

At Risk of HomelessnessExperiencing Homelessness
Security Deposit

A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Security Deposit?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast 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

Cancelof
Rental Assistance

A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Rental Assistance?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast 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

Cancelof
Rental Arrears

A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Rental Arrears?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast 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

Cancelof
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

CityState

Zip Code
Company/Vendor Contact Name

First NameLast 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

Cancelof
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

CityState

Zip Code
Company/Vendor Contact Name

First NameLast 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

Cancelof
Move-In Items
Do you have an entry for Move-In Items?

Yes
Total Amount
Company/Vendor/Website
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast 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)

Cancelof
Moving Fees

A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Moving Fees?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast 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

Cancelof
Public Transportation
Do you have an entry for Public Transportation?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast 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

Cancelof
Other
Do you have an entry for Other?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast 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

Cancelof
Additional Expense(s)
Do you have an entry for an Additional Expense?

Yes
Expense Category
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company/Vendor Contact Name

First NameLast 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

Cancelof
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 NameLast Name
Title*
Elevance Approving Staff Signature*

Clear
Elevance Staff Signature/Submission Date*

MonthDayYear
Date
Should be Empty:

MSFS Elevance Health Community Connect Flex Fund Request Form

Elevance Staff Requestor Information

Member Information

Security Deposit

Rental Assistance

Rental Arrears

Utility Deposit

Utility Arrears

Move-In Items

Moving Fees

Public Transportation

Other

Additional Expense(s)

Signatures