PORTLAND REFUGEE SUPPORT GROUP
HOME
Newsletters
Who We Are
What We Do
Arabic عربي
COVID-19
Events/Gallery
Volunteer
Resources
Donations
PRSG's ISOS Financial Aid Request
Long-Term Aid (2 months or more)
WARNING
:
If you use your smartphone to submit this form we may not receive it. Please use a computer. Thank you!
NOTE: ISOS never gives aid in the form of cash
.
Please complete every section of this application.
If a question does not apply to your situation, enter N/A in that field. All fields with an * are required fields. If any required field is left blank, the application will flag the error and decline submission until corrections are made. If any section that is applicable is left blank, the application will be declined due to lack of information.
ISOS needs a minimum of 1 week to respond to the request. ISOS respects the privacy of all applicants. Any information that is submitted to ISOS is only used internally by ISOS board members to determine eligibility. We assure you that we do not share your information with anyone without your knowledge/consent and all information submitted is kept strictly confidential.
ISOS is not to be held liable for any legal violation from the applicant for misuse of the funds and services rendered to them.
Client Details
*
Indicates required field
Today's Date (month/day/year)
*
CLIENT LEGAL NAME
*
First
*
Middle
*
Last
Other Names Used
*
Date of Birth
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
At This Address Since:
*
Primary Phone Number:
*
Secondary Phone Number:
*
Email
*
Driving License Number Or ID Number
*
Issuing State
*
Ethnicity: (Please select)
*
African American
Asian
Hispanic
Middle Eastern
Somali
White
Other
Languages Spoken (Select all that apply)
*
Arabic
English
Spanish
Somali
Other
To choose more that one press "Ctrl" when selecting
Please check the following that applies to you:
*
Domestic Violence
Disabled
Ex-prisoner
Retired
Veteran
Homeless
Residence Status
Social Security Number
*
OR / WA Resident Since (Date: MM/DD/YYYY)
*
Residence Status
*
Green Card Holder
U.S. Citizen
Other
Green Card #:
*
Naturalization Date (MM/DD/YYYY):
*
In case Residence Status is "Other", please explain below.
*
Marital Status
Marital Status
*
Single
Married
Widowed
Divorced
Separated
Is your marriage legally recognized by Oregon or Washington state?
*
Yes
No
Legally divorced?
*
Yes
No
Date of Divorce:
*
Legally separated?
*
Yes
No
Date of Separation:
*
Household
# of people living with you?
*
# of people dependent on you?
*
# of children living with you?
*
Please provide details below.
Name 1:
*
Age 1:
*
Relation 1:
*
Name 2:
*
Age 2:
*
Relation 2:
*
Name 3:
*
Age 3:
*
Relation 3:
*
Name 4:
*
Age 4:
*
Relation 4:
*
Name 5:
*
Age 5:
*
Relation 5:
*
Name 6:
*
Age 6:
*
Relation 6:
*
Employment Status
Employment Status
*
Employed
Unemployed
Self-Employed
Employer's Name
*
Employer's Address
*
Line 1
Line 2
City
State
Zip Code
Country
Employer's Phone
*
Length Of Employment
Years
*
Months
*
Can We Contact Your Employer?
*
Yes
No
If No, please provide reason below
*
If you are unemployed, are you enrolled in the following: (check all that apply)
*
Apprenticeship Program
Work Source
Jobs Plus Programs
Specify
Comments: (500 char. max.)
*
Financial Status (Income)
Net Employment Income:
*
Food Stamps:
*
Worker's Compensation:
*
Pension:
*
Veteran's Benefits:
*
College Financial Aid:
*
Work-Study:
*
Alimony (Spousal Support):
*
Monthly TANF:
*
Child Support:
*
Family Assistance Monthly:
*
Section 8:
*
Rent Subsidy:
*
Social Security Income:
*
Social Security Disability:
*
Rent Subsidy Termination Date:
*
Unemployment Income:
*
Unemployment Income Termination Date:
*
Other (specify):
*
Total Income:
*
Financial Status (Expenses)
Rent/ Mortgage:
*
Child Care:
*
Electricity:
*
Child Support:
*
Heating Gas:
*
Water:
*
Phone:
*
Car Insurance:
*
Car Payment:
*
Health Insurance:
*
Transportation:
*
Food:
*
Car Gasoline:
*
Medical:
*
Credit Card:
*
Others:
*
Other Expenses : Please Itemize list
*
Total Expenses:
*
Requested Assistance and Plan
If income exceeds expenses, why the need for support?
*
How much financial aid is requested?
*
How will the aid be used?
*
If applying for rental assistance, please email a copy of your Rental Lease contract to: yasser@pdxrsg.org
Is this a one-time request?
*
Yes
No
Provide outline of your action plan to be self-sufficient: (500 char. max.)
*
Please provide what agencies/ resources are involved with your ability to be self-sufficient (500 char. max. or email full details to: yasser@pdxrsg.org):
*
Active Community Partners/Sponsors (Volunteer) Information
Volunteer Full Name:
*
Volunteer Phone Number:
*
Volunteer Email address :
*
Attachments (Required Documents)
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.
The client needs to provide to the Sponsor the completed and signed ISOS Release of Information (ROI) Form.
Click here for the Release of Information Form
*
I will email the Release of Information Form ASAP to: yasser@pdxrsg.org
If applying for rental assistance, please email a copy of your Rental Lease contract to: yasser@pdxrsg.org
Note that the client's case will not be considered without the required documents. Thank you!
∙
Make sure you click the SUBMIT button well, until you see the confirmation message "
Thank you. Your information has been submitted
" or you see the message "
Please correct the highlighted fields
".
Submit
HOME
Newsletters
Who We Are
What We Do
Arabic عربي
COVID-19
Events/Gallery
Volunteer
Resources
Donations