Broker Inquiry Form

Human Resources Administration311

SNAP & CA Housing & Prevention Services Health Assistance Other Benefits & Services

This Inquiry Form is for brokers to submit their inquiries/concerns/issues to Human Resources Administration’s Housing Services Team for review.

The range of issues that the team can review are listed below.

Upon completion of this form, you will receive a follow-up email along with a reference number detailing next steps.

* Indicates required fields

What subsidy are you reaching out about?*

Are you a registered user on CurRent?* Yes No

Have you completed the DSS Authorized Point of Contact Designation Form?* Yes No

Broker or Brokerage Information

Please confirm:* I have a client who receives a housing subsidy from the Human Resources Administration (HRA)

Brokerage Name*

Broker First Name*

Broker Last Name*

Broker or Brokerage Mailing Street Address*

Broker or Brokerage Mailing Apartment/Suite

Broker or Brokerage Mailing City*

Broker or Brokerage Mailing State*

Broker or Brokerage Mailing ZIP Code*

Your Email*
We will send you a confirmation email with the correspondence number that is associated with your request to this email address once this form is submitted. You will also receive a response to this email address that asks you to send supporting documents.

Your Phone Number*

Landlord First Name*

Landlord Last Name*

Tenant Information

Tenant First Name*

Tenant Last Name*

Tenant Street Address*

Tenant Apartment/Suite

Tenant City*

Tenant State*

Tenant ZIP Code*

Certification

I certify that I am the person submitting this form online and that the information provided is accurate and complete to the best of my knowledge. I further certify that I have read, understood, and voluntarily agreed to submit the information required to process my request.

Enter your name in lieu of signature*

Date Submitted*

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