Approved partner agencies use only.
ALL fields starred are required, otherwise it is optional.
The information recorded in this form will be maintained with strict confidentiality and will only be used by DFB staff for processing furniture requests, making contacts for outcome measures and for reporting demographical/statistical information.
Total Number of People in Household
How many are children?
Is head of household employed?
Household Income (approximately):
Source of Income:
Please select a language
If other, please indicate:
Delivery service needed?
All referrals that pick up furniture from DFB warehouse MUST bring: 1) Their own loading assistance and 2) their own tie-downs and protective coverings.
The following information is used for demographic reporting only
What primary reason initiated your client's need for furniture? *
Preferred Transaction Method:
Agency Credit Line
Invoice to Agency
(Due to DFB within 21 days from date of purchase)
Please list here any specific/pertinent information regarding this referral that is relevant to DFB and its handling of this referral.
Disclaimer: All furniture items at DFB are sold "as is". These items are lightly used donated goods. The DFB will ensure that any known defect or problem with a furniture item is revealed prior to its purchase. The DFB does not offer any warranties or guarantees for any of the items purchased. Additionally, the DFB will not be responsible for items picked up by the client or member agency that are damaged during transfer.