New Service Request

Personal Information

Household Members

[{viewVars.title}]

[{viewVars.validations.members}]

Please fill all the required fields before proceeding further

PLEASE DO NOT APPLY IF YOUR CLIENT HAS RECEIVED SUPPORT FROM ISOS within the last 12 months.THIS FORM MUST BE COMPLETED ON BEHALF OF THE CLIENT BY A SPONSOR ASSOCIATED WITH AN AGENCY/ORGANIZATION OR THE CLIENT'S HEALTHCARE PROVIDER. THE SPONSOR IS RESPONSIBLE FOR PROVIDING INFORMATION TO ISOS ABOUT THE CLIENT'S SITUTAION. (ISOS does not accept applications directly from clients.)Eligibility Criteria:• The client must have been a resident of Oregon or Southwest Washington for at least six months.• The client must be a citiizen, resident or a legal immigrant of US.• The client must provide a well-defined action plan for becoming self-reliant.• For rent assistance, a valid rental lease contract and lease ledger is required.• For financial hardship resulting from medical condition a Dr.’s letter is required.• The sponsor must be able to provide proof of the client's current income, expenses, bank statements, and the previous year’s tax return upon request.Processing Timeline:• It takes at least 10 business days to respond to a request.

ISOS respects your privacy. Information you submit is only used to determine eligibility.

ISOS is not to be held liable for any legal violation from the applicant for misuse of the funds and services rendered to them.

First Name

[{viewVars.validations.firstName}]

Middle name

[{viewVars.validations.middleName}]

Last Name

[{viewVars.validations.lastName}]

Other Names Used

[{viewVars.validations.otherNames}]

DOB

[{viewVars.validations.dob}]

Primary Phone Number

[{viewVars.validations.phone}]

Secondary Phone Number

[{viewVars.validations.phone2}]

[{viewVars.validations.email}]

Client's Address Line 1

[{viewVars.validations.address}]

Client's Address Line 2

[{viewVars.validations.address2}]

City[{viewVars.validations.city}]

Zip

[{viewVars.validations.zip}]

State

[{viewVars.validations.state}]

At This Address Since

[{viewVars.validations.addressSince}]

Driving Licence Number Or ID Number

[{viewVars.validations.idNumber}]

Issuing State

[{viewVars.validations.issuingState}]

Ethnicity

[{viewVars.validations.ethnicity}]

Other - Ethnicity

[{viewVars.validations.otherEthnicity}]

Languages Spoken

[{viewVars.validations.Language}]

Other - Languages Spoken

[{viewVars.validations.otherLanguage}]

Please check the following that applies to you:

[{pr}]

Comments

OR/ WA Resident Since

[{viewVars.validations.residentSince}]

Immigration Status

[{viewVars.validations.residenceStatus}]

Green Card #

[{viewVars.validations.greenCardNum}]

Please explain

[{viewVars.validations.otherResidenceStatus}]

Naturalization Date

[{viewVars.validations.naturalization}]

Marital Status

[{viewVars.validations.marital}]

Is your marriage legally recognized by OR or WA state?

[{viewVars.validations.marriageLegal}]

Legally divorced?

[{viewVars.validations.divorced}]

Date of Divorce

[{viewVars.validations.divorceDate}]

Legally separated?

[{viewVars.validations.separated}]

Date of Separation

[{viewVars.validations.separationDate}]

# of people living in your household including you?

[{viewVars.validations.peopleNum}]

# of people working in the household?

[{viewVars.validations.dependentNum}]

# of children living with you?

[{viewVars.validations.childrenNum}]

Add a Household Member.

Household Member #[{$index+1}]

Name

Age

Relation

Employed

Monthly Income

Employment Status

[{viewVars.validations.employment}]

Employer's Name

[{viewVars.validations.employerName}]

Employer's Address

[{viewVars.validations.employerAddress}]

Employer's Address2

[{viewVars.validations.employerAddress2}]

Employer's Phone

[{viewVars.validations.employerPhone}]

Years Of Employment

[{viewVars.validations.employmentYears}]

Months Of Employment

[{viewVars.validations.employmentMonths}]

Can We Contact Your Employer?

[{viewVars.validations.contactEmployer}]

Please provide reason

[{viewVars.validations.noContactEmployer}]

Are you enrolled with any organization? please provide details

[{pr}]

Please specify

[{viewVars.validations.specifyUnemployed}]

Add income.

Source of income	Amount	Action

Rent Subsidy Termination Date

Unemployment Income Termination Date

Other (specify)

If you are legally separate or divorced, are you receiving child support or alimony?

[{viewVars.validations.receivingChildSupport}]

If yes, how much?

[{viewVars.validations.yesReceivingChildSupport}]

Net Income: [{actions.getTotal(viewVars.applicant.incomes)| currency:$:2}]

Add Expense.

Expense	Amount	Action

Other Expenses : Please Itemize list

Total Expense: [{actions.getTotal(viewVars.applicant.expenses)| currency:$:2}]

If income exceeds expenses, why the need for ISOS Support?

How much total financial aid is requested from ISOS?

[{viewVars.validations.totalAid}]

How will the aid be used? (Please provide breakdown of the total amount being asked. Name the months and category of expense)

[{viewVars.validations.aidUsed}]

If applying for rental assistance, please upload the Rental Lease contract.

[{viewVars.validations.documentation}]

View [{viewVars.applicant.documentation}]Delete

If the financial difficulty is due to disability or health issues, please attach Dr.'s letter explaining

[{viewVars.validations.documentation2}]

View [{viewVars.applicant.documentation2}]Delete

The client needs to provide to the Sponsor the completed and signed ISOS Release of Information (ROI) Form. The Sponsor is to attach the signed ROI Form in the Resource Aid Form.
The Release of Information Form link

[{viewVars.validations.documentation3}]

View [{viewVars.applicant.documentation3}]Delete

Is this a one-time request?

[{viewVars.validations.oneTimeRequest}]

Provide outline of your action plan to be self sufficient. (Please describe the reason behind your current financial difficulties)

[{viewVars.validations.actionPlan}]

Please list all other agencies or resources that are contributing to your self-sufficiency.

[{viewVars.validations.agencies}]

Add a Partners.

Partners #[{$index+1}]

Organization Name

Type of Assistance Provided

Case Worker Name

Case Worker's Phone Number

Case Worker's Email address

Name of Sponsor’s Organization

[{viewVars.validations.sponsorName}]

Sponsor Email

[{viewVars.validations.sponsorEmail}]

Sponsor Phone Number

[{viewVars.validations.sponsorPhone}]

I declare as an authorized signer, that this filing has been examined by me and is, to the best of my knowledge and belief, true, correct, and complete. Making false statements in this document can warrant denial of request. I also authorize ISOS to contact all listed sponsors to provide any and all relevant information to ISOS.

I understand that transactions and/or signatures in records may not be denied legal effect solely because they are conducted, executed, or prepared in electronic form and that if a law requires a record or signature to be in writing, an electronic record or signature satisfies that requirement.

[{viewVars.validations.consent}]

Electronic Sponsor Signature

[{viewVars.validations.signature}]

Unemployed adults in the home, please identify employment barriers. (Check all that apply)

[{pr}]

Specify

Have you have experienced any physical health, mental health, and/or substance use issues, what impact has it had on your daily functioning and ability to maintain stable housing?

[{viewVars.validations.healthIssues}]

On a scale from 1-10, How motivated are you to change your current circumstances?

Have you taken any steps/actions to change your current circumstance?

[{viewVars.validations.changeSteps}]

If so, please elaborate on steps made, success/challenges, and impact:

Disclaimer: These questions will not affect your eligibility for assistance from RBF

Do you identify with any of the following religions? (Check all that apply)

[{pr}]

Specify

How do you engage with your religious/spiritual beliefs? (Check all that apply)

[{pr}]

Specify

Is there any curiosity toward your faith or any other faith?

If so, please elaborate:

Is there a plan to further your spiritual growth in the future?

If so, please elaborate:

Were you referred to the Robert Brooks Foundation? If so, could you share who referred you?

[{viewVars.validations.whoReferred}]

Do you give us permission to share your name and contact information with trusted partners who might be able to assist in areas where the Robert Brooks Foundation cannot?

[{viewVars.validations.permission}]

Have you received assistance from our organizations in the past?

[{viewVars.validations.receivedAssistance}]

Are you facing any spiritual challenges that you would like support with, such as prayer or counseling?

[{viewVars.validations.spiritualChallenges}]

please explain if applicable

[{viewVars.validations.spiritualChaInfo}]

Household Members

As you are a previous client you don't need to complete this step. Please submit the form.

Housing Status

Household Type

Adults in Household

[{viewVars.validations.adults}]

Children in Household

[{viewVars.validations.children}]

Seniors in Household

[{viewVars.validations.seniors}]

Estimated Annual Income

[{viewVars.validations.income}]

Any history of child welfare / foster care involvement?

If so, please describe:

Are there any past or current domestic violence issues?

If so, please describe:

Add a Household Member.

Household Member #[{$index+2}]

First Name

Last Name

Relationship

DOB

SSN (Full or Last 4)

Phone

Gender

Ethnicity

Language

[{$item}]

[{k}]

Race

[{$item}]

[{k}]

Health Insurance

[{$item}]

[{k}]

Marital Status

Highest Level Education

Employment Status

Veteran Status

Disability?

School/Daycare Name

Add income.

Source of income	Pay Period	Amount	Action

Add benefit.

Benefit	Amount	Action

Please add at least one household member.

Thank you for your submission. Your case# is: [{viewVars.case}]
We will contact you shortly.

[{viewVars.title}]

Please Read

Client Details

Residence Status

Marital Status

Household Members

Household Member #[{$index+1}]Delete

Employment Status

Monthly Income

Monthly Expenses

Requested Assistance

Active Community Partners/ Sponsors Information

Partners #[{$index+1}]Delete

Sponsor Details

Signature

Work

Health

Change

Spiritual

Disclaimer: These questions will not affect your eligibility for assistance from RBF

Referral

Household Members

Household Member #[{$index+2}]Delete

Household Member #[{$index+1}]

Partners #[{$index+1}]

Household Member #[{$index+2}]