Yamhill County SIT Funding Request Form January 4th 2022 - December 9th 2022

UPDATED 05/10/2022

!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 Specialist: 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 Specialist 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 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.*

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 eviction notice
• 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/community-programs/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.

!We are ONLY accepting URGENT requests for McMinnville/Lafayette families! We have gas vouchers available.

Question Title

* 1. Referring agency/Provider contact information

Name (First & Last)

Company/Agency

Email Address

Phone Number

Question Title

* 2. Is this request urgent? Does it meet urgent guidelines? (see above) If so, please contact Rubi at rramirez@yamhillcco.org after filling out this request.

Question Title

* 3. By when is this funding needed?

Date by when payment needs to be made (Please note that this is only a guideline for SI coordinator and we cannot guarantee that payment will be made by this date)

Date

Question Title

* 4. Individual/family contact information

Name (First & Last)

DOB

Phone number

Address

City

Preferred language

Question Title

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

Question Title

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

Question Title

* 7. Amount requested (Please provide a specific $ amount). The max is $300 for team funds

Question Title

* 8. 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)

Question Title

* 9. 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)

Question Title

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

Question Title

* 11. Which resources have you already accessed?

YCAP

Salvation Army

Give A Little Foundation

Habitat for Humanity

NWSDS

St. Vincent

Has not sought out assistance

Other (please specify)

Question Title

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

Question Title

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

Question Title

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

Adult men (20+)

Adult women (20+)

Youth 13- 19 yrs old

Children 7-12 yrs old

Children 0-6 yrs old

Question Title

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

American Indian / Alaska Native

Asian or Asian American

Black / African American

Hispanic / Latinx

Middle Eastern / Northern African

Native Hawaiian / Pacific Islander

Race/Ethnicity - Other

White / Caucasian

Decline to respond

Question Title

* 16. Does any child in the household/family unit have a diagnosed disability?

Question Title

* 17. Is family engaged in CPS? (for tracking purposes only)

Question Title

* 18. is family homeless or at risk for homelessness? (for tracking purposes only)

Question Title

* 19. Is anyone in the household on YCCO Medicaid insurance?

If so, who?

Question Title

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

Yes

Please specify amount needed. Range is from $5 to $100, in $5 increments. Only request what the client actually needs

Question Title

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

Medical/Dental/Mental Health appointments

WIC

DHS

Employment related

Groceries/Food pantries

N/A - Does not need gas vouchers

Question Title

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

Oregon Health Plan (OHP)

Supplemental Nutrition Assistance Program (SNAP)

Women, Infants, and Children (WIC)

Temporary Assistance for Needy Families (TANF)

Employment Program

Family Support Program

Mental Health Program

Community food pantry

Section 8 Housing

Home visitation

SSI/SSD

Child welfare involvement

None of the above

Other (please specify)

Question Title

* 23. Preschool Promise (PSP) offers free, high-quality preschool (in select communities) for children ages three and four in families living at or below 200% the FPL. Is the family interested in learning more about PSP?

Yes

Thank you for all that you do for our community!