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4. NON-PROFIT AGENCY INFORMATION
6. Agency Name*
7. Agency Contact Name*
9. Agency Contact Phone*
10. Agency Contact Email*
12. Funding Source*
    -- Select One --CHGESG - CountyESG - StateCoCDRFTHASDGEPP
13. Project Type*
    -- Select One --Permanent Supportive HousingRapid Re-HousingTransitional HousingShelter
14. Inspection Type*

    1. New / Initial
    2. Annual
15. Unit Occupied? *
    -- Select One --NoYes
17. HOUSING UNIT INFORMATION
19. Tax Parcel Number

    Parcel number can be found on the Assessor-Treasurer's ATIP website. https://atip.piercecountywa.gov/app/parcelSearch/search

    
    

21. On-Site Contact Name*
23. On-Site Phone or Email*
25. Complex Name
27. Street Address*
    Provide physical address, not the address for the leasing office. This address will need to match up exactly with the invoicing.
28. Unit Number
30. City*
31. Zip*
32. Number of Bedrooms*
    Number of bedrooms the client will be occupying.
34. Number of Children Under Age 6*
    Number of children under the age of 6 residing in the unit.
36. Check one that applies:*

    1. Literally Homeless, unsheltered
    2. Literally Homeless, sheltered
38. Pre-Inspection Checklist:*

    Pre-Inspection Checklist  Link

    1. I have reviewed the Pre-Inspection Checklist
40. Additional Comments
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field