This document is an approval form for emergency relocation funds from the Adult Protective Services department. It collects information about a client's emergency situation, what other resources have been explored, how the funds will be used to resolve the emergency, and the case manager's plan to prevent future emergencies. The form approves dollar amounts under various expense codes and requires signatures for approval and issuance of funds.

1. APS EMERGENCY RELOCATION FUND APPROVAL FORM
FORM: APS ERF #1 (Revised November 2003)
Date: County Name:
Client Name: Age: Case #:
Client’s disability: Medicare Medicaid SSI CCSP VA
Income (amount & source):
DESCRIBE THE EMERGENCY SITUATION:
HAVE ALL OTHER RESOURCES BEEN EMPLORED OR EXHAUSTED?
Family Community State Federal Other
HOW WILL THE FUNDS BE USED TO REMOVE CLIENT FROM EMERGENCY SITUATION?
WHAT IS CASE MANAGERS PLAN TO PREVENT REOCCURANCE?
Enter Dollar Amount Approved:
Code 03 Emergency Shelter Cost
(Rent PCH NH Motel Own home )
Code 14 Emergency Food, Clothing/Personal Needs/Utilities
Code 15 Emergency Medical Needs
Code 18 Other Emergency Needs
TOTAL APPROVED Date Waiver approved:
Approved By: Position: Date:
Accounting Issued funds: Name: Date:
ERF-1 Emergency Relocation Fund Approval Form (Rev. 11-03) Page 1 of 1