HUD Agency Referral, Gwinnett

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Use this form if you are with an agency and are referring a client to PCCI for housing assistance.

Agency Information

AgencyThe name of your agency

Your NameYour full name

Agency PhonePlease enter without spaces or punctuation

Agency EmailYour email address.

Name

DVIs the client currently fleeing or attempting to flee a domestic violence situation?

PhonePlease enter without spaces or punctuation

EmailLeave blank if no email

IncomeTotal combined gross monthly income for all adult household members. Program income limit is 50% AMI.

HMISVeteran's HMIS ID number, if known.

IdentifierIf the client is not in HMIS, enter their date of birth and/or the last 4 digits of their social security number.

AdultsHow many adults are in the household?

ChildrenHow many childre (under 18) are in the household?

NotesVeteran's address or approximate location, details of situation, or anything that we may need to know to best assist the veteran.

Please do not fill in this field.

302 Decatur St. SE, Ste.101
Atlanta, GA 30312
Hours of Operation: Monday – Friday, 8:30am – 4:30pm
There is no cost for services.

If you are in need of housing assistance, visit the Get Help section of our Web site.
Phone: (404) 215-9991
Email: visit the Contact page.