Youth Transition Funds Request w/instructions CD 78 1/13
|[pic] |Transition Funds Request |
|Independent Living Program | |
Link to instructions.
|Select all that apply: | Chafee housing Driver’s education fees |
| |Education and Training Voucher (ETV) |
| |Housing subsidy Housing/one-time payment |
| |ILP discretionary Laptop |
| |Aftercare services Yes No |
|Youth/young adult's name: |Case number/person number: |
| | / |
| |
|Proposed discretionary/emergency expenditures |
| |
|( |Housing start-up (bedding, towels, kitchen utensils, food staples, etc.) |$ | | |
|( |Special work equipment/clothing (tools, uniforms, etc.) |$ | | |
|( |Transportation (bus fees, bicycle, driver’s education course, etc.) |$ | | |
|( |One-time move-in fees (rent, deposits: cleaning, utility, security) |$ | | |
|( |Personal documents (Oregon ID, driver’s license, birth certificate, etc.) |$ | | |
|( |Tutor (private and institutional; i.e., Sylvan Learning Center) |$ | | |
|( |Secondary education costs (GED or SAT fees, laptop, application fees, sports fees, etc.) |$ | | |
|( |Post-secondary costs (tuition/fees, laptop, books, supplies, transportation, etc.) |$ | | |
|( |Other (identify): | |$ | | |
| |TOTAL: |$ |0[pic]0.00 | |
Note: Approved expenditures will have a direct relationship to the youth/young adult’s goals as set forth in their comprehensive transition plan (CF69A).
|Transition goal area(s): | Community connections/supportive relationships |
|(Select all that apply) |Education Employment |
| |Health Housing |
| |Life skills Transportation* |
|Provide a description of what the funds are to be used for and how they will assist and support youth/young adult's transition plan: |
|Provider name: | |Phone number: | |
|Street address: | |
|City: | |State: | |Zip: | |
|Payment request for: | |
|Mailing: Where payment is to be sent. If there is an ODHS caseworker assigned, payment to the youth/young adult must be mailed to the local Child Welfare branch|
|office. If payment is for an Aftercare Service client, payment can be sent to the ILP Provider office or directly to the young adult. |
| |
|Where payment is to be mailed: |
|Name: | |Phone number: | |
|(Name Provider, Local Branch Office, Resource Parent or Young Adult) |
|Street address: | |
|City: | |State: | |Zip: | |
|*Direct deposit options are available for youth/young adults |
|Confirmed with youth via: | | | | |
| | |Youth’s |Worker’s initials/date |
| | |initials/date | |
|Agreement statement: The youth/young adult, ODHS or Tribal Nation worker and ILP provider, or if an Aftercare Services client, the young adult and ILP Provider,|
|all agree that the costs relate and support the youth/young adult to achieve the goals indicated on their transition plan. All acknowledge that the youth/young |
|adult is to provide the ODHS caseworker (or if an Aftercare Services client, then the ILP Provider) with a receipt for the expenditures and the receipt will be |
|sent to ILP.Central@dhsoha.state.or.us within seven (7) days of purchase. The youth/young adult understands if funds are misused, the youth/young adult must |
|repay the funds to ODHS. |
|ODHS or Tribal Nation worker signature: | |Date: | |
| | | | |
|ILP Provider signature: | |Date: | |
| |
|Youth/Young Adult signature: | |Date: | |
|(can be verbal/written approval) | | | |
| The youth/young adult's signature above will allow ODHS to receive a refund for driver courses. |
|If the youth did not sign above, identify how youth confirmed and then select dropdown of who confirmed: |
|Worker initials: | | |
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