Sonoma County Black Forum Financial Assistance* Application

Sonoma County Black Forum Financial Assistance* Application

The Sonoma County Black Forum Financial Assistance Program will offer financial support to address essential basic needs of many vulnerable, furloughed, unemployed, and underemployed Sonoma County residents. Our approved funding will provide a one time Financial Assistance in the amount of $1,200 to 225 Sonoma County residents. Funding is for food assistance, a fuel/gas card, rent or general housing assistance. Funding is provided by the County of Sonoma, through the American Rescue Plan Act of 2021. The Sonoma County Financial Assistance program is administered by Sonoma County Black Forum. *This project is being supported in whole by federal award number SLFRP0246 awarded to the County of Sonoma by the U.S. Department of the Treasury.
The Black Therapy Voucher Program will launch Friday, November 4. If you’d like to apply, please click on the BTVP link below:

BTVP APPLICATION
FINANCIAL ASSISTANCE DOCUMENTATION REQUIREMENTS AND VERIFICATION

Documentation will be required to confirm each household's eligibility status. Due to the expected demand, please be mindful that meeting these criteria DOES NOT entitle or guarantee a household assistance. Assistance is based on the greatest need of applicants. After Sonoma County residents' rental status is verified, a one time emergency rent, security deposit payments or general housing assistance will be provided. NOTE: ANY MISREPRESENTATION WILL RESULT IN A REJECTION OF APPLICANT.
Who Will See My Information

Applicant information provided in the application process will be kept confidential, and helps us determine eligibility for program participation. Demographic data may be anonymously used to seek potential grant funding to support our future programs or to extend current funding. For information addressing concerns about disclosure of Personal Identifiable information in ARPA Community Resilience Program Data Reporting, please click on the Data Collection and Release of Information Link below.
Data Collection and Release of Information
Digital Signature *

Clear
APPLICATION

Please provide the information below to participate in the SCBF Financial Assistance Program. Your information will be kept confidential, and helps us determine eligibility for program participation. Demographic data may be anonymously used to seek potential grant funding to support our future programs or to extend current funding. This program is open to all Sonoma County residents regardless of immigration status. Sonoma County Black Forum will not require applicants to state their immigration status. *Applicants must be current Sonoma County residents (minimum 6 continuous months).
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province
Zip Code *
Other Zip Code if not listed above:
Preferred method for us to reach you *

Phone Call Email Text
Phone Number
Please enter a valid phone number.
Email
example@example.com
Residents must provide verification that RENTAL PAYMENT(S) DUE by providing ONE of the following: *

Do you have a lease/rental agreement? If yes, provide a current lease/rental letter signed by the applicant and the landlord. No, I do not
If you do not have a lease agreement, provide ONE of the following: *

Rent due statement/letter from the landlord or management company 3 day notice (must include amount of rent outstanding) Other formal attempt to collect rents or notify tenant of rents due No, I do not have any of the above A signed and dated Affidavit of Truth that the information Applicant has provided is true, correct, and complete.
Please upload your current lease/rental agreement or other current forms of Documentation such as 2 rent receipts, 2 cancelled checks or money orders. TWO CURRENT DOCUMENTS ARE REQUIRED. In order for your application to be reviewed, it must include two current documents with your first and last name on them. *

function SvgDhtupload(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 014.374 3.242 15.065 15.065 0 012.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0146.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 01-1.185-.5 1.62 1.62 0 01-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 003.03-2.846 13.53 13.53 0 001.95-3.9 14.23 14.23 0 00.686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 00-2.582-3.636 12.857 12.857 0 00-3.742-2.478 11.054 11.054 0 00-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 01-4.374-.975 11.673 11.673 0 01-3.61-2.661 13.173 13.173 0 01-2.478-3.9A12.073 12.073 0 010 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 013.268 3.215 18.628 18.628 0 012.266 4.216zm-11.964 13.44l6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 01-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 01-.87.448.959.959 0 01-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 01.396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052z", fill: "none" }))); }

Cancel of
Marital Status *

Single (never married) Married, or in a domestic partnership Widowed Divorced Separated Prefer not to answer
Total Number of Children under 18 *
How many family members, including yourself, do you currently live with? *
Are there multiple families living in this household? *

Yes No
Annual Household Income *
What California assistance program do you currently or anticipate accessing to support you? Select all that apply. *

Supplemental Nutrition Assistance Program (SNAP)/ CalFresh Temporary Assistance for Needy Families (TANF) Head Start and/or Early Head Start Women, Infants, & Children (WIC) Unemployment Insurance Children’s Health Insurance Program, Childcare Subsidies through the Child Care Development Fund (CCDF) Program, or Medicaid National School Lunch Program (NSLP) and/or School Breakfast (SBP) Programs Medicare Part D Low-Income Subsidies Pell Grant Supplemental Security Income (SSI) Section 8 Vouchers Household receiving services provided by Tribal governments Low-Income Home Energy Assistance Program (LIHEAP) None Other
Please list any other Government Assistance Agency you currently or anticipate accessing to support you?
How have you been impacted by COVID-19? Check all that apply: *

I was laid-off or lost my job because of COVID-19. I lost some or all of my income. I have been evicted or lost my housing because of COVID-19. I have not been impacted by COVID-19.
What are your greatest needs at this time? Check all that apply: *

Economically struggling Housing Providing for dependent children (age 18 and under) living in the home Being a current or former foster youth, ages 18-24 Food insecurity Low income No income Leaving an abusive relationship Access to education Access to Healthcare Computer Needs Utility shut off Survival is threatened I do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a bench, in a car, or in a park)
What else would you like us to know about your needs, priorities, or concerns? What additional support do you need at this time?
Demographic Questions

Applicant information provided in the application process will be kept confidential, and helps us determine eligibility for program participation. Demographic data may be anonymously used to seek potential grant funding to support our future programs or to extend current funding. Individual data may be aggregated into anonymous group data for use in public reports and to fulfill equity standards for ARPA funding that is required by the federal government. Sonoma County Black Forum will not deny assistance to an otherwise eligible household on the basis of race, ethnicity, gender, sexual orientation, or religion.
Racial/Ethnic Identity: Please select all that may apply. To add an identity not listed, please use the open description line. One or more may be selected. *

African-American/Black Asian Caucasian/ White Latino/a/x, Hispanic, or Spanish origin Indigenous/Mixteco, Triqui, Chatino, or other Indigenous Community Puerto Rican Cuban Another Hispanic, Latino/a/x Spanish/European origin Native American/Indigenous Peoples/First Nations Peoples (American Indian) or Alaskan Native Native Hawaiian or other Pacific Islander Prefer not to answer Other
Other Racial/Ethnic Identity that's not listed above.
What best describes your gender identity? *
Do you think of yourself as . . . *
What is your age? *

Under 18 18 - 44 45 - 75 75+
How did you find out about the Sonoma County Black Forum's Financial Assistant Program? *

Bay Area Regional Health Inequities Initiative EARTHseed Farm to Pantry Friend or Family Member Media/Radio La Plaza NAACP North Bay Black Chamber of Commerce Petaluma Blacks For Community Development Sonoma County Black Forum's website, email, word of mouth United in Kindness Santa Rosa Junior College Sonoma State University Sebastopol Senior Center Other
To receive a confirmation email, please provide your email below.
example@example.com
Affidavit of Truth

By my digital signature below, I affirm that the information I’ve included in this application is truthful to the best of my knowledge and understanding.
This is a fill in the field. Please add appropriate fields and text.
First Name Last Name
SignatureCityCounty
Post Assessment Survey Request: To document the effectiveness of the program and to ensure future funding of this program, we invite you to complete an anonymous brief Post Assessment Survey about the Financial Assistance Program. In appreciation of completing our brief survey, you will receive $25.00.
Your response below will not impact funding decisions. *

Yes, I agree to take a brief survey. No, thank you.
Should be Empty:

Sonoma County Black Forum Financial Assistance* Application

FINANCIAL ASSISTANCE DOCUMENTATION REQUIREMENTS AND VERIFICATION

Who Will See My Information

APPLICATION

Affidavit of Truth