YAMHILL COUNTY SIT FUND REQUEST JANUARY 2024 - DECEMBER 2024

Yamhill County SIT Funding Request Form January 2024-December 2024

! FOR COMMUNITY PARTNERS USE ONLY!

PLEASE DO NOT FORWARD THIS LINK TO CLIENTS. IF YOU ARE A CLIENT PLEASE CONNECT BACK WITH YOUR RESOURCE WORKER.

If you have applied for financial assistance with YCCO Flex Funds (FF) please wait to apply for SIT funds until FF had made a final determination on the funding request. SIT is unable to process a funding request that has a pending FF application.

*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 Maribel Dobbins, Yamhill County SI Specialist: mdobbins@yamhillcco.org or 971-461-0521.

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

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 $400.*

Urgent Guideline criteria, must meet one for the following:
• an eviction notice or deposit
• 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

NOTE: Effective 01/16/2024, the SITs voted to increase payments from $400 to $800 specifically towards Housing Stabilization needs please review the criteria below:

* An eviction notice has been served due to unpaid rent, deposit, or mortgage payment.

*Any other time-sensitive issue that puts the client/family in imminent danger and/or puts their health at risk.

SIT funds will not cover application fees/cost directed towards the intention of applying for an apartment/housing unit.

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 6

Question Title

* 1. Has the individual or family received funding within the last 2 years

Yes

Question Title

* 2. Does this request meet urgent criteria?

Yes - an eviction or deposit

Yes - a utility shut off notice

Yes - an urgent item or purchase needed that would help secure employment or housing/shelter

Yes - a medical condition that would require immediate resolution

Yes- urgent prescription, lice treatment/kits for lice outbreak

Yes - a time sensitive issue in which the client/ family is in imminent danger of their health is at risk

More or less. This needs to be addressed within a week or two.

no.

no. this need can wait to be addressed until the next SIT meeting

Question Title

* 3. Has the individual or family explored other resources for this need

Yes

Question Title

* 4. Please list the two resources accessed and the outcome of the interaction

Resource 1

Resource 2

Other:

Question Title

* 5. Referring agency/Provider contact information

Name (First & Last)

Company/Agency

Email Address

Phone Number

Question Title

* 6. Individual/family primary contact information

First/Last name:

DOB:

Phone number:

Address:

City

Preferred Language:

Question Title

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

Applicant name/DOB:

Person#2/DOB:

Person#3/DOB:

Person#4/DOB:

Person#5/DOB:

Person#6/DOB:

Question Title

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

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? How will the family/individual pay for this expense next month? Please be as descriptive as possible and answer all the questions, incomplete applications will be returned.

Question Title

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

Question Title

* 11. Amount being requested (please provide specific dollar amount). The max is $400.00 for team funds.

Question Title

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

Adult (18-64)

Older Adult (65+)

Youth 13-17 yrs old

Children 7-12 yrs old

Children 0-6 yrs old

Question Title

* 13. Indicate the number of people by gender who will be served because of funding

Female

Male

Transgender

Gender Non-conforming

Other

Question Title

* 14. Indicate the number of people by race/ethnicity who will be served because of this funding.

American Indian/ Alaska Native

Asian / Asian American

Black/ African American

Hispanic/ Latinx

Middle Eastern/ Northern African

Native Hawaiian/ Pacific Islander

White/Caucasian

Combination of two or more

Race/Ethnicity -Other

Question Title

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

Yes

Decline to answer

Question Title

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

Yes

Decline to answer.

Question Title

* 17. Is family homeless or at risk for homelessness? (for tracking purposes only)

Yes

Decline to answer.

Question Title

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

Yes

Decline to answer.

Question Title

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

Oregon Health Plan (OHP)

Supplemental Nutrition Assistance Program (SNAP)

Women, Infant, 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

* 20. 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