GNF Test Page

Step 1 of 6

Name:

First

Middle

Last

Email:

Date of Birth:

Are you married or living with a significant other?

Number of children living in the household?

Ages:

Physical Address:

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address same as Physical Address:

Mailing Address:

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone:

Secondary Phone:

Length of time living or working in San Miguel County, West end of Montrose, or Ouray County:

Do you plan to stay in the area once this crisis is over?

Upload Proof of Employment Here (Paystubs, offer letter, etc.):

Click or drag files to this area to upload. You can upload up to 2 files.

Current in the last 60 days.

Upload Copy of Lease Agreement or Mortgage Statement Here:

Click or drag a file to this area to upload.

Current in the last 60 days.

Upload Bank Statement showing current cash on hand:

Click or drag files to this area to upload. You can upload up to 2 files.

Current in the last 60 days.

Upload copies of the bill/s that you are requesting help with.

Click or drag files to this area to upload. You can upload up to 3 files.

Current in the last 60 days.

Release of Information

If you are applying for rental or mortgage assistance, please complete the Release of Information (ROI). This allows our team to speak directly with your landlord, property manager, mortgage company, or funder to verify required information and help prevent delays in processing your application.

I, the tenant of

Address

Address Line 1

Address Line 2

City

State

Zip Code

family gas) needed

hereby consent to the Landlord or Property Management Company staff sharing my personal tenancy information with the representative of the of Tri-County Health Network in regard to the Good Neighbor Fund or Ouray County Response Fund.

This information may include, but is not limited to, residency status and rent amount.

Tenant Name

Date

Good Neighbor Fund Representative

Date

If you have any issues uploading you can email attachments directly to GNF@tchnetwork.org.

Please be sure to include your name in the email.

Attestation:
I certify that the information given on this application is accurate and complete to the best of my knowledge and belief. I also understand that false statements or information are grounds for denial of assistance and/or prosecution of fraud, as allowed by Colorado law.

Release of Information Consent
By signing this application, I understand that my information may include protected health information. I authorize the release of my information to any person or agency necessary to meet my service needs, including, but not limited to, vendors and partner agencies. This information will be used solely for the purpose of assessing, arranging, and meeting my individual service needs.

I release Tri-County Health Network and its partners from any liability related to the sharing of this information.

Applicant Signature:

Clear Signature

Applicant Signature Date:

If YES,

Most Recent Employer:

If new job lined up,

What are your sources of monthly income? (* Proof of income sources required) Enter 0 if not applicable.

What are your monthly expenses? Please provide documentation of these expenses when you submit your application. Enter 0 if not applicable.

What other resources have you pursued? You must provide an answer for each (approved, terminated, denied etc.)

Social Determinants of Health Questionnaire:

Release of Information

I, the tenant of

hereby consent to the Landlord or Property Management Company staff sharing my personal tenancy information with the representative of the of Tri-County Health Network in regard to the Good Neighbor Fund or Ouray County Response Fund.

This information may include, but is not limited to, residency status and rent amount.

Attestation:
I certify that the information given on this application is accurate and complete to the best of my knowledge and belief. I also understand that false statements or information are grounds for denial of assistance and/or prosecution of fraud, as allowed by Colorado law.

I release Tri-County Health Network and its partners from any liability related to the sharing of this information.

If YES,

Most Recent Employer:

If new job lined up,

What are your sources of monthly income? (* Proof of income sources required) Enter 0 if not applicable.

What are your monthly expenses? Please provide documentation of these expenses when you submit your application. Enter 0 if not applicable.

What other resources have you pursued? You must provide an answer for each (approved, terminated, denied etc.)

Social Determinants of Health Questionnaire:

Release of Information

I, the tenant of

hereby consent to the Landlord or Property Management Company staff sharing my personal tenancy information with the representative of the of Tri-County Health Network in regard to the Good Neighbor Fund or Ouray County Response Fund.

This information may include, but is not limited to, residency status and rent amount.

Attestation: I certify that the information given on this application is accurate and complete to the best of my knowledge and belief. I also understand that false statements or information are grounds for denial of assistance and/or prosecution of fraud, as allowed by Colorado law.

I release Tri-County Health Network and its partners from any liability related to the sharing of this information.

Attestation:
I certify that the information given on this application is accurate and complete to the best of my knowledge and belief. I also understand that false statements or information are grounds for denial of assistance and/or prosecution of fraud, as allowed by Colorado law.