Request for Funds
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Form request number if applicable
Funds requested
Referrer name
Referrer email address and phone number
Mailing Address of Agency
Funds payable to (Payee must not be a client)
County jurisdiction of child(ren)
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In what city do(es) the child(ren) live?
Is/Are the child(ren) in legal custody of the county and placed in kinship/foster care?
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Number of children in family
Age(s) of Children
Specific need requested
Number of twin beds requested
Number of bunk beds requested
Number of full beds requested
Are any full beds requested for adults?
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Number of futons requested
Number or toddler beds requested
Number of cribs requested
List any additional furniture being requested
If furniture was requested was it from:
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Is bedding requested?
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If bedding is requested, please list the size and quantity needed
Is this request related to a COVID-19 hardship
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Is any part of this request not for children?
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If any part of this request is for an adult, please explain
Explanation of the family's situation
Does the family get welfare assistance?
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If the family gets welfare assistance, what assistance do they receive?
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What is the family's yearly income?
Please list other agencies working with the family
Please list any other resources that have been explored
This form has been updated 12/7/2021
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