2025 Acorn Fund - Referral Form
Email Address: info@acornfundpocatello.org
Contact Alisha Bailey or Amy Shelton: (208) 557-4237

This form is to be filled out by referring case manger and client.  
Please do not distribute this form directly to clients.

Acorn Fund Referral Requirements:
  • Experiencing Housing Insecurity
  • Experiencing Unemployment - Seeking Employment
  • Working with a case manager in order to have follow up and successful outcomes. 
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Email *
1. Client's Current Legal Name (First, Middle, Last Name) *
2. Client's Phone Number 
3. Acorn Notes (For Acorn Use Only - No response Needed)
4. Client's Email
5. Name of person completing form (Acorn representative or referring case manager) *
6. Case Manager Phone Number  *
7. Name of Agency Referring Client
Clear selection
8. Is the client experiencing housing insecurity? *
Required
9. Client Employment Status *
10. Please indicate what items client is applying for: *
Required
11. Client's experiencing homelessness who were born in Idaho or California and need a birth certificate for the purpose of obtaining a state I.D. qualify for one free birth certificate. 
These can be filled out by case managers: FOLLOW INSTRUCTIONS CAREFULLY - MUST BE NOTARIZED. 
Call Acorn with questions 208-557-4237

Client's experiencing homelessness who have had a previous State ID or Driver's License in Idaho qualify for one free State ID. 
12. Your agency gives permission for Acorn to sign  ITD 3530 Relief Agency Form, in your behalf for the Idaho Transportation Department, which states that your client is indeed experiencing homelessness (not just housing insecurity)? *
13. Client's Name on Birth Certificate (First, Middle, Last Name/Maiden Name) *
14. Birthdate
MM
/
DD
/
YYYY
15. Gender on Birth Certificate
Clear selection
16. Where was client born? (State, City, County)
17. What state did you have your last State ID card or driver's license in? *
18. Has the client had a legal name change for any reason? (Marriage, Adoption, Divorce etc.) Check all that apply
19. Why does the client need the ID/Birth Certificate/Clothing etc? *
Required
20. Does Client have any of the following documentation? (Check all that apply)
21. Client's mailing address? 
22. Has the client notified the post office of this address? (Client's need to fill out a form at the post office for new addresses so the Post Office will deliver official documents.)
Clear selection
23. Was this person released from prison or jail in the last year? (This question helps us know how we can best help those who were recently released.)
Clear selection
24. If the client answered YES to being in PRISON, what prison were they in? Were they given a state ID when they were released from prison? 
(We are keeping data on this statistic for legislative purposes as Idaho prisons are supposed to give out state ID cards before individuals leave.)
25. Comments and/or questions for Acorn
26. OFFICE USE ONLY (Cost of ID, Birth Cert. Clothing Etc.)

27. Acorn Fund Pocatello Inc. Release of Information

 I, [Client's Name], hereby give permission to Acorn Fund Pocatello and its volunteers to use the information provided on this form to assist me in obtaining the necessary documents. 

I understand that this information will be used exclusively for the purpose of retrieving essential documents, which may include scanning and saving photo IDs, birth certificates, and social security cards. I authorize Acorn Fund Pocatello and its volunteers to assist me in obtaining the vital records needed for employment and/or housing.

Please Type Client's Name and Date as signature
 *

28. Witness Statement and Release of Liability

I, [Client's Full Name], hereby affirm that all documents utilized in coordination with Acorn Fund Pocatello Inc. to assist me in obtaining my vital records and state-issued identification are, to the best of my knowledge, valid and legally obtained.

Furthermore, I release and hold harmless Acorn Fund Pocatello Inc., its agents, representatives, and affiliates, from any liability or responsibility for illegal actions, including but not limited to identity fraud, that may arise from the use of said documents. I acknowledge that I am solely responsible for the accuracy and legality of the personal information provided and used in this process.

Signed,
Please Type Client's Name and Date as signature
 *
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