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: | | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download