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2. AGENCY NAME
4. PROJECT NAME
6. TOTAL FUNDING REQUEST
8. ADDRESS
10. Street Number
11. Street Name
12. Street Type
13. Apt #
15. City
16. State
17. Zip
19. CONTACT
20. PHONE #
24. AGENCY EXECUTIVE NAME
26. PHONE #
27. E-MAIL
31. TAX STATUS (select one):

    1. Nonprofit 501(c)3
    2. Local or state agency
    3. Fiscal Sponsor (Attach a letter confirming the arrangement, including the contact name and information for the sponsor)
33. Previous Emergency Fund Recipient?

    1. No
    2. Yes
34. In what year did you receive Emergency Funds?
36. If your agency has been funded within the past five years from the Emergency Fund, please describe what has been funded in the past.

40. NOTE: 
    The Emergency Fund is intended to assist agencies with a short-term urgent funding need that has or will significantly interrupt essential services or impact the health and safety of the homeless population.

    Examples Include:

    • Natural disasters (e.g. fire, flood, tornado, storm damage, loss of utilities)
    • Emergency needs (e.g. phase-out costs associated with closing a program due to a sudden loss of funding, equipment failure, civil disturbance, severe weather events, or other conditions determined by the Cowlitz County Healthy Officer to be an emergent threat to public health and safety.)

    * All projects must be eligible activities as specified by the State of Washington for the use of Homeless Housing Document Recording Fees.

    *  Applicants should be aware that this is a short-term funding opportunity, and that each application is considered on its merits within established eligibility criteria. The filing of an application is not, nor should be, perceived as a guarantee of funding. 

    Emergency Fund Requests will not be considered for the following purposes: 

    • To "bail out" agencies due to mismanagement or budget shortfalls. 
    • To assist individual applicants. 
    • To provide services outside of Cowlitz County.
    • For sectarian or religious purposes. 
    • For political purposes. 
    • To support ongoing program work.  

44. SECTION 1: Please explain the emergency or urgent reason for this funding request. 

46. 1A. What created the need for emergency funding?
48. 1B. Will this be a recurring funding need?
50. 1C. How will the situation that caused the emergent need be avoided in the future?
52. 1D. Include any other helpful information about this funding request.

54. SECTION 2: Please describe how the funds will be used. 

56. 2A. What expenses will be paid with this funding?
58. 2B. Are there other funds contributing? (Include in-kind: volunteers, donations, etc.)

60. SECTION 3: Describe who will be served by this request.

62. 3A. How many people/households will be served?
64. 3B. Over what time period?
66. 3C. Include any other helpful information about the individuals to be served.

68. SECTION 4: Describe what will happen if this request is not funded.

70. 4A. If this funding request is not approved, how will this affect the project?

72. SECTION 5: Describe resources your agency could provide to meet this need. 

74. 5A. Reserve funds available.
76. 5B. Allowable use of reserve funds.
78. 5C. Have reserve funds been used in the last 12 months for this need?

80. SECTION 6: Describe involvement from other agencies. 

82. 6A. Are other agencies providing funding or staff support for this need?
84. Please attach proposed Program Budget*

    Please attach a budget that provides an overview of the total cost of the project and that details the costs being requested for reimbursement through this fund. Please also include any requests made through other fund sources that have been committed, pending, or declined. The budget should include a breakdown of what the funds would go towards (personnel, supplies, equipment, etc).

Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit

* indicates a required field