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Quinault Indian Nation
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Crisis Statement Fillable PDF
Name
(Required)
First
Middle
Last
Suffix
Please provide a statement that details your specific crisis, which will be resolved with Diversion Services and how the services will assist your family unit in not needing a monthly cash grant.
(Required)
Head of Household Signature
(Required)
Date
MM slash DD slash YYYY
Significant Other Signature (If Applicable)
Date
MM slash DD slash YYYY
Diversion Services Request
Listed below are allowable items that diversion funds may be spent on. Indicate the items and corresponding dollar amount that you are intending to pay with the diversion funds. Please note that the indicated items must total $2000. In the event that there is an existing overpayment for either adult member of the family unit, it may be necessary to make adjustments to the amount of the diversion. Overpayments can be collected at up to 25% of the amount of the diversion payment.
Diversion Fund Usage
(Required)
Check the items you intend to pay. Then enter the amounts below. Please note that the indicated items must total $2000.
Housing
Utilities
Training
Education
Child Care
Mental Health, Chemical Dependency or Domestic Violence Services
Higher Education or Work Related Clothing and/or Supplies
Developmental or Learning Disability Services
IDA Accounts
Required Program Documentation (State Certified Birth Certificates)
Food
Fuel
Auto Repairs
Transportation
Auto Insurance
(State Certified Birth Certificates) $ Needed for the following members of the family unit:
Housing Amount
Utilities Amount
Training Amount
Education Amount
Child Care Amount
Mental Health, Chemical Dependency or Domestic Violence Services Amount
Higher Education or Work Related Clothing and/or Supplies Amount
Developmental or Learning Disability Services Amount
Car Payment Amount
IDA Accounts Amount
Required Program Documentation (State Certified Birth Certificates) Amount
Food Amount
Fuel Amount
Auto Repairs Amount
Transportation Amount
Auto Insurance Amount
In order to protect your private information the completed PDF form will be encrypted with a password. Please type a memorable password below.
Password
(Required)
The completed PDF form will be emailed to you please provide an email address below.
Email
(Required)
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