Region 3 Day 1 Families Fund Referral

Region 3 Day 1 Families Fund Referral

Complete this form to make a referral to the Day 1 Families Fund. The purpose of these funds is to quickly rehouse families. A case manager referring a household should be actively having housing problem solving conversations with the household and provide ongoing case management, as needed and identified by the household.

To be eligible for funds, a household must:

have at least one adult and one dependent child
be experiencing homelessness

Head of Household Information

HMIS ID (if available)

Head of Household First Name*

Head of Household Last Name*

Number of Adults in the household*

Number of children in the household*

This household is not eligible for funds.

If you have further questions regarding this referral, please reach out to Ric Smith - ric.smith@wpcog.org

Where is the household sleeping tonight?*

Select or enter value

This household is not eligible for funds.

If you have further questions regarding this referral, please reach out to Ric Smith - ric.smith@wpcog.org

Does the household currently have income?

Select

Service Transaction Information

Activity Type*

Diversion - this transaction will help divert the household from staying in a facility-based shelter.

RRH - this payment will rehouse the household in a new unit.

Select

Service Code*

Choose the option(s) that best match the financial request.

Select

Service Cost*

What is the total cost of the request? Please note there is a maximum amount of $2,500 per household.

Payment Type*

How should this transaction be made?

Select or enter value

Link to online purchase*

When is the payment needed?*

Other Details

Please outline additional details, as needed.

Attachments*

Please attach all applicable documentation. If documents are missing or incomplete, the process will be stalled.

HMIS SSO Project Entry Form for EACH household member
HMIS ROI
Invoice/Payment Request
Lease Agreement (if signing a new lease)

Drag and drop files here or

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