Payment RequestTo be completed by the landlord only.

Yellowstone Country Assistance Network
Payment Request

This is not a form for Tenants. This form is for Landlords or Property Managers Only.
Tenant Information
Name of Tenant to be credited with payment *

First NameLast Name
Rental Unit Address*

Street Address

Apartment or Unit Number (if applicable)

CityState / Province

Postal / Zip Code
Park CountyHot Springs CountyTeton County
Tenant Move-In Date*

MonthDayYear
Date
What type of housing unit is this assistance for?*
Security Deposit / Move-In Fees (If Applicable)Rent due this monthPast-Due Rent Arrears BalanceLate Fees (if applicable)Other
Date Rent was (is) due for Tenant *

MonthDayYear
Date

Breakdown of Rent Owed by Tenant *

Rows	Amount	Notes/Month
Security deposit or fees due (0 if none)
Current month’s rent (0 if already paid) Add due date in notes.
Past-due rent balance (0 if none)
Late fees (enter 0 if none)
Next month’s rent (pre-approved only, or enter 0)
Amount needed to bring tenant current (0 balance until next rent due date)

YesNo
YesNo

Landlord Vendor Details:

Required for Payment and IRS Tax Compliance (1099 Issuance)
Individual/sole proprietorC corporationS corporationPartnershipTrust/estateLLC. C = C corporationLLC. S = S corporationLLC. S = S corporationLLC. P = PartnershipOther
Legal Business Name or Individual Name as Listed on Tax Returns (Name on 1099)*
This is the legal entity name used for IRS reporting purposes.
Required Taxpayer Identification Number (TIN/SSN)*
1099 Mailing Address (Legal/Tax Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload a signed 2024 IRS W-9 (current calendar year). Payment cannot be issued without a current W-9 on file.

Cancelof
YesNo
Upload a signed 2024 IRS W-9 (current calendar year). Payment cannot be issued without a current W-9 on file.

If your classification is Individual/Sole Proprietor, Partnership, or Trust/Estate, a current IRS Form W-9 is required to verify your tax information for 1099 reporting.
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Name of Payee (check recipient)
If different from Legal Business or Individual Name on Tax Returns (Name on 1099)
Address to send check if different from name on tax returns

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CheckACH
Contact Name *

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
Providing your email allows us to better communicate payment status.
Partial payment accepted. I acknowledge that a partial payment from YCAN may help resolve the tenant’s past-due balance and prevent eviction.Full payment is required to stop the eviction. I require the full past-due balance listed on this form to stop eviction proceedings. If the full amount is not paid, eviction proceedings may continue.Other
Total Amount Due for This Request (USD)*
Landlord Certification: By signing below, I certify that the amounts listed in this request are true, accurate, and complete to the best of my knowledge. I further certify that this request is submitted in good faith for eligible rent and/or landlord-billed utility charges on behalf of the tenant listed above.I affirm that I am not requesting payment for services or fees for which the tenant is not eligible, and that I do not have a personal or financial relationship with the tenant that would create a conflict of interest.*

Clear
Please provide us with any notes or list any additional fees.
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Copy of lease, statement, or eviction notice.

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Your information will be encrypted and accessible only to the end user via password protection. Processing typically takes approximately one week after we receive all required documents and verify the tenant’s eligibility. Please also be aware that mailed payments may take up to two weeks to arrive.

YCAN is a Wyoming-registered nonprofit operating under the name Yellowstone Country Assistance Network of Park County, Wyoming. Our mailing address is PO Box 600, Basin, Wyoming 82410. You may reach our CEO by phone at 307-754-2073, extension 4, or by secure email at YCANSecureInbox@proton.me

Please note that YCAN outsources vendor management and payment processing to The Align Team, located in Cheyenne, Wyoming. A representative from The Align Team may contact you on our behalf to coordinate payment arrangements.
Should be Empty:

Rows	Amount	Notes/Month
Heat
Electricity
Water
Other (Explain)
Late Fees (Applicable only if listed on your ledger)
Total Amount Required to Bring Tenant Current

Tenant Information

Landlord Vendor Details: