Funding Request Form - UPDATED 9/9/2021

!FOR COMMUNITY PARTNER USE ONLY!
PLEASE DO NOT FORWARD THIS LINK TO CLIENTS. IF YOU ARE A CLIENT PLEASE CONNECT BACK WITH YOUR RESOURCE WORKER.
Welcome to the Yamhill County Service Integration Funding Request Form. We value our partners and are thankful that Yamhill County Families have advocates such as you! If you have questions about this form or need assistance filling it out please contact Rubi Ramirez, Yamhill County SI Coordinator: rramirez@yamhillcco.org or 503-455-8044

If you are requesting assistance for rent/mortgage/deposit, please obtain a W9 from your client's landlord and email it to SI Coordinator at rramirez@yamhillcco.org. If you are requesting assistance for any bill, please email a copy of the latest bill to SI Coordinator at rramirez@yamhillcco.org. Failure to do so will result in a delay in the payment process. 

If you are requesting specific items from Amazon or other sites, please include the links (QUESTION 10) below with the exact amount including shipping. 

For West Valley (Grand Ronde/Willamina) requests, please visit: 
https://www.co.polk.or.us/fco/si/service-integration-online-funding-request

Basic Funding Guidelines:
Service Integration Team dollars are intended to meet an immediate, one-time need that achieves a measurable outcome towards health, wellness, and/or self-sufficiency. SIT funds are a last resort when all other community resources have been accessed or unavailable. Funding requests are situation-dependent, but not more than $300.* 
*COVID related funding cap amounts are as follows: Rent: $800 Deposit $800 Mortgages $800 Utilities $500. Must answer YES to question #1 and #2 to be eligible for the expanded amounts

Measurable Outcomes:
Service Integration funds should be focused on meeting needs that can provide some measurable outcomes (whether big or small).

Urgent Guideline criteria, must meet one for the following: an eviction notices
• an urgent item or purchase needed that would help secure employment or housing/shelter
• a medical condition that would require immediate resolution
• a utility shut off notice
• urgent prescriptions, lice treatment/kits for a lice outbreak
• a time sensitive issue in which the client/family is in imminent danger or their health is at risk

Before submitting a request please read the complete Service Integration Funding Guidelines which are found on the website: https://yamhillcco.org/about-us/service-integration-teams/ 

*NEW* After a request is approved, you will have 60 days to submit documents needed for payment. If documents are not received in 60 days, the request will be closed and a new request must be submitted. 

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* 1. Will this funding reduce the risk of contracting COVID, assist with receiving COVID-related treatment, reduce exposure to disease, or assist with social distancing or protective measures? and/or Is this need the direct result of a COVID-related loss of income, quarantine, or layoff? (Required to receive expanded funds)

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* 2. Does your client attest to have contacted YCAP for additional supports? (Required to receive expanded funds)

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* 3. Referring agency/Provider contact information

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* 4. Individual/family contact information

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* 5. Please list all household members, full name (including children) and DOB

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* 6. What is the outstanding balance or total amount due? (before any assistance) (ex: monthly rent $1200 or utility bill is $543.21, etc.)

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* 7. Amount requested (Please provide a specific $ amount). The max is $300 for team funds, if you are wishing to request more from the team please explain why.  See expanded funding caps for COVID related rent/mortgage/deposit/utility assistance above in the opening section.

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* 8. By when is this funding needed?

Date

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* 9. Type of request: E.g. car repair, utility assistance, rent assistance, etc.

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* 10. Who is SIT paying? Enter the name of the agency/ apartment complex or enter links of items to be purchase here, with quantities of each. (ex: Wildhaven property management or PGE)

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* 11. Please provide a detailed description of what the funds will be used for. How will this improve the client's health, well-being and/or self sufficiency? What is the family/individual's circumstances?  (The information provided in this section will be used on the voting survey. Please be as descriptive as possible, incomplete applications will be returned)

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* 12. What barriers are preventing the family/individual from meeting this need on their own?

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* 13. How will the family/individual pay for this expense next month?

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* 14. Indicate the number of people who will be served because of funding. If activity was for a large group, estimate the total number.

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* 15. How does the client identify their race/ethnicity? (Select all that apply)

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* 20. Is this client/family in need of gas vouchers?

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* 21. What is the purpose for the gas vouchers? (check all that apply)

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* 22. Which resources have you already accessed?

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* 23. Please list how much money each resource has provided and for what

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* 25. What services/resources is the individual/family receiving?

Thank you for all that you do for our community!

T