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.
IMPORTANT MESSAGE - Applications for the Sonoma County Black Forum’s Financial Assistance program submitted on and after Tuesday, February 28, will be placed on a Waitlist. Waitlist applicants will be moved to an active status if application is complete and when a Financial Assistance opening occurs. We appreciate your patience in advance. By clicking the Submit button at the bottom of this page you acknowledge that your application will be placed on the Waitlist for Financial Assistance. We appreciate your patience in advance.
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

The Sonoma County Human Services Department would like to have a better understanding of the clients we serve, through its data collection. The data also allows the Sonoma County Black Forum to seek further funding for our programs. We ask that you read the Release of Information (ROI) and sign on the signature line. Please know that the ROI is voluntary and if you choose to not sign it, funding decisions will not be impacted. To read and/or sign the ROI that addresses concerns about the disclosure of Personal Identifiable information in ARPA Community Resilience Program Data Reporting, please click on the Data Collection and Release of Information Link below.
Click below for English:

Data Collection and Release of Information English

Haga clic abajo para español:

Recopilación de Datos y Divulgación de Información Español
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 NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

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

Phone CallEmailText
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 company3 day notice (must include amount of rent outstanding)Other formal attempt to collect rents or notify tenant of rents dueNo, I do not have any of the aboveA 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 below, such as rent receipts, cancelled checks or money orders, utility bills, etc. 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.
Documentation #1:*

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Documentation #2:*

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Marital Status*

Single (never married)Married, or in a domestic partnershipWidowedDivorcedSeparatedPrefer 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?*

YesNo
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)/ CalFreshTemporary Assistance for Needy Families (TANF)Head Start and/or Early Head StartWomen, Infants, & Children (WIC)Unemployment InsuranceChildren’s Health Insurance Program, Childcare Subsidies through the Child Care Development Fund (CCDF) Program, or MedicaidNational School Lunch Program (NSLP) and/or School Breakfast (SBP) ProgramsMedicare Part D Low-Income SubsidiesPell GrantSupplemental Security Income (SSI)Section 8 VouchersHousehold receiving services provided by Tribal governmentsLow-Income Home Energy Assistance Program (LIHEAP)NoneOther
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 strugglingHousingProviding for dependent children (age 18 and under) living in the homeBeing a current or former foster youth, ages 18-24Food insecurityLow incomeNo incomeLeaving an abusive relationshipAccess to educationAccess to HealthcareComputer NeedsUtility shut offSurvival is threatenedI 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/BlackAsianLatino/a/x, Hispanic, or Spanish originMiddle Eastern or North AfricanIndigenous/Mixteco, Triqui, Chatino, or other Indigenous CommunityPuerto RicanCubanAnother Hispanic, Latino/a/xSpanish/European originNative American/Indigenous Peoples/First Nations Peoples (American Indian) or Alaskan NativeNative Hawaiian or other Pacific IslanderWhitePrefer not to answerOther
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 1818 - 4445 - 7575+
How did you find out about the Sonoma County Black Forum's Financial Assistant Program?*

Bay Area Regional Health Inequities InitiativeEARTHseedFarm to PantryFriend or Family MemberMedia/RadioLa PlazaNAACPNorth Bay Black Chamber of CommercePetaluma Blacks For Community DevelopmentSonoma County Black Forum's website, email, word of mouthUnited in KindnessSanta Rosa Junior CollegeSonoma State UniversitySebastopol Senior CenterOther
Other organization if not listed above.
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.
The Black Therapy Voucher Program launched Friday, November 4. If you’d like to apply, please click on the BTVP link below:

BTVP APPLICATION
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