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Homeless Management Information Systems (HMIS) Correction Request Form

  1. Homeless Management Information Systems (HMIS) Correction Request Form

  2. Title II Compliance

    In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website.

  3. Type of Request: Delete Enrollment, Delete Service, Duplicate/Merge Client, Change Enrollment

  4. Type of Request*

    Please check all the changes being requested

  5. Full program name that the client is enrolled in

  6. Date Client Enrolled

  7. Full program name that the client is enrolled in

  8. Date Client is enrolled

  9. Describe the method of verification.

  10. Please fill in a detailed report of the issue or correction that you are experiencing

  11. Upload a screen shot or file of what you are experiencing.

  12. Leave This Blank:

  13. This field is not part of the form submission.