Payment Information Request Form

Payment Information Request Form

For Northwest Minnesota Multi-County HRA's Self Sufficiency Programs
In order to receive scholarship and/or grant funding the following items MUST BE complete before making a purchase/payment or having any work completed! Along with this completed form, you will also need to return the verification items the Self Sufficiency staff requested from you. Completing this form is not a guarantee of funding. All requests must be submitted, reviewed, and approved prior to services being completed or items being purchased.
Full Name:*
Address:*

Street Address

Apt/Unit Number

CityState

Zip Code
BRIEFLY describe item/service that is being requested:*
Full cost of request:*
The total amount the item/service will cost
Amount you are requesting for help:*
Name of organization this item/service would be purchased/completed:*
Name of Contact Person at organization:*
Organization's Phone Number:*
Please enter a valid phone number.
Organization's Mailing Address*

Mailing Address

Unit/Suite Number

CityState

Zip Code
Your account number, if applicable:
This is to put on the payment, if approved.
BREIFLY describe what you would do without receiving funding:*
Please check each box below to acknowledge each item:
I understand that the information provided will be released only to Northwest Minnesota Multi-County HRA and the organization listed above. Any use, other than that specified above, or any subsequent release of this information, is expressly forbidden under the Minnesota Data Privacy Act, unless my written consent is obtained.
I understand that participation in either the Family Self Sufficiency or Resident Opportunity & Self Sufficiency Program at Northwest Minnesota Multi-County HRA is required to receive any scholarship/grant funding available to myself and/or my household under the Self Sufficiency Programs.
I understand that any scholarship/grant funding is not guaranteed, must be approved before the service/item is purchased/completed, can be denied, and are based on current funding.
I understand that if approved, the scholarship/grant will not cover 100% of the requested item/purchased. I will be responsible for paying a portion of it myself.
Applicant Signature:*

Clear
Date*

MonthDayYear
Date
**If applicant is under age 18, the parent/guardian must sign this form**
Should be Empty: