Emergency Funding Referral Form

Have you experienced hardships due to the COVID-19 pandemic?Pro Action may be able to help!
Through emergency funding, income eligible households (those whose income is at or below
200% of poverty level; income verification will be required) can seek assistance with:
• Basic Needs: Food, infant formula, cleaning supplies, hygiene and first aid products,
PPE, clothing and shoes. (back to school items would also qualify)
• Homeless Assistance: Assistance for homeless individuals and families to include
security deposits.
• Rent/ Mortgage Assistance: Emergency Rent and/or Mortgage Support to avoid
eviction and/or foreclosure proceedings
• Emergency Utilities: Emergency utility support (water/sewer/gas/electric) to avoid
disconnect or deposits necessary to start service.
• Household Items: Items to support/stabilize customers establishing stable housing – i.e.
bedding, bath, kitchen, etc.

Please complete this form.

Steuben and Yates County Emergency Funding Referral Form
- Must be for an immediate need not covered by an existing funding source
- Must agree to disclose other assistance received
- PAYMENT CANNOT BE MADE DIRECTLY TO CLIENT
- Any questions, please contact Isabella Haber at 315-313-2536 or via email at haberi@proactioninc.org
Referrer Information
Date*

MonthDayYear
Date
Referral made by:
Organization:*
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referrer email
example@example.com
Applicant Name:*
Family Size*
Address:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Purpose for Request for Funds (describe need):*
Name, Phone Number, and Address of where payment should be made:*
Amount requested:*
Date Needed:*

MonthDayYear
Date

Please list other funding sources attempted, received or anticipated:

Have you experienced hardships due to the COVID-19 pandemic?Pro Action may be able to help!