Child Welfare
Independent Living Program / Youth Transition Funds Request

CF 0078 (01/13)

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Link to instructions.

Check one of the following: ILP discretionary

Housing SubsidyChafee Housing Housing/one-time payment
Educational andTraining Voucher (ETV) Drivers Education Fees

Youth’s name: / Case number/person number:
/
Proposed discretionary/emergency expenditures
 / Housing start-up (bedding, towels, kitchen utensils, food staples, etc.) / $
 / Special equipment (tools, uniforms, etc.) / $
 / Transportation (bus fees, bicycle, driver’s education course, etc.) / $
 / One-time move-in fees (rent, deposits: cleaning, utility, security) / $
 / Personal documents (Oregon ID, driver’s license, birth certificate, etc.) / $
 / Tutor (private and institutional; i.e., SylvanLearningCenter) / $
 / Secondary education costs (GED or SAT fees, application fees, sports fees, etc.) / $
 / Post-secondary costs (tuition/fees, books, supplies, transportation, etc.) / $
 / Other (identify): / $
TOTAL: / $ / 0.00

Note:Approved expenditures do not include articles that do not have a direct bearing on achieving the youth’s goals as set forth in his/her comprehensive transition plan. A comprehensive transition plan must be completed (CF69A or B) and entered on the Youth Transitions tab in OR-Kids.

Transition goal area(check all that apply):
EducationEmploymentHousingHealth
Community connections/supportive relationshipsTransportation* Life skills
Provide a description of what the funds are to be used for and how they will assist the youth’s plan for independence:
Other resources explored: / Foster family / ILP donations / Other DHS funds
Financial aid / Work Force Investment Act / Foster parent association or group
Payment request for: / Direct payment to youth / Reimbursement to foster parent
Payment to provider/school / If other than youth, list provider name or number below:
Mailing: Where payment is to be sent. A payment payable to the youth must be mailed to
the local office. Check one: Provider Local office
If local office, provide all of the following: / Phone no:
Worker name: / Local office:
Youth’s name: / Case number/person number:
/
Agreement statement:The youth, DHS or tribal worker and ILP provider all agree that the costs are necessary to assist the youth in achieving the youth’s plan of independence. All acknowledge that the youth is to provide the DHS caseworker with a receipt for the expenditures and the receipt will be sent to the ILP desk within seven (7) days of purchase. Youth understands if funds are misused, the youth must repay the funds to DHS.
For a youth who has requested funds for a driver’s course, by initialing below, the youth also agrees to allow DHS to send their identifying information to the Oregon Department of Transportation. This will allow DHS to receive a refund for driver courses.
Youth’s initials: / ILP provider’s initials:
If youthdid not initial above, select the type of worker who verified youth’s approval and understanding of expectations: DHS Tribal ILP
Worker initials:
Confirmed with youth via:
Phone conversation, date:
Email, date:
Text, date:
DHS or tribal worker signature: / Date:

CF 0078 (01/13)

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