1. The applicant must be actively enrolled in the I - CARE Community Services Block Grant (CSBG) program and making progress towards goal attainment as determined by the Family Support Services Director and Case Manager Please be advised that financial assistance decisions are determined on a case - by - case basis with consideration given to the availability of funding CSBG participants must be enrolled in the CSBG program for at least 30 days before they are eligible to receive financial assistance

2. The level of financial assistance may vary based on the amount of the request at the time the request is received

3. The application period for submission of financial assistance applications will be July 1 until November 15 and January 15 until June 30 annually Only in emergency situations or for services related to tuition, and education and employment supports will consideration be given to financial assistance being granted between November 16 and January 14

4. A separate application must be completed for each financial assistance request

5. The Request for Financial Assistance must be submitted and a response must be received prior to any commitment being made for I - CARE to assist Participants are required to manage their monthly household expenses and will be allowed one (1) emergency payment for rent / mortgage and one (1) utility payment (electric, water, fuel) per program year (July 1 - June 30) Any additional payments for household emergency assistance must be approved by the Executive Director, case - by - case, depending on the circumstances

6. No financial assistance will be rendered for deposits

7. Participants are not entitled to a refund for payments made to vendors paid with CSBG funds

8. The applicant must exhaust other available funding resources (i.e. Salvation Army, Iredell Christian Mission, Mooresville Christian Mission, and / or DSS) and show proof (letter of support / denial) before any support from I - CARE will be granted

9. Program funding priority will be given to requests for eviction prevention, utility cut - off prevention, employment / education / training supports (i.e. gas, bus tickets, employment - related clothing, employment / education / training - related car repairs, etc.) Maximum funding will vary from year to year based upon the program budgets I - CARE, Inc. reserves the right to make the decision as to whether an item requested meets the funding criteria and / or is on the list of approved items

10. Participants requesting assistance for gas to travel to and from school, work, medical appointments or other locations as necessary for goal attainment may be assisted with gas to meet obligations Participants will accompany the CSBG staff person to the gas vendor with whom l - CARE, Inc. has an account The staff person will use the credit card to make the gas purchase per the approved amount on the financial assistance application The original receipt will be attached to the I - CARE, Inc. purchase order for Business Office purposes A copy of the receipt will be maintained in the participant's file as proof of purchase Gas requests will be restricted to gas only with a maximum of 10 gallons per request

11. Financial assistance for any educational expenses such as books, fees, tuition, supplies and materials will be based on the severity of each case, and determined by the Family Support Services Director and the Case Manager Current course registration must be submitted to the Case Manager for proof of enrollment

12. Participants with a status of probation for financial aid and / or academics may not be approved to use CSBG funds to pay for educational expenses other than short - term occupational skills training courses An official letter from the college stating financial aid status must be submitted in order for I - CARE to consider assisting with payment If the participant fails a course for which I - CARE CSBG has provided financial assistance, the participant forfeits the privilege for future educational assistance for a period of one (1) year based on the course enrollment date Financial assistance will be determined, case by case, and will require supporting documentation

13. Financial assistance payments will be paid directly to the vendor No direct financial assistance to program participants is allowed All assistance is provided directly to a specified vendor using a voucher system with signature approval from the Family Support Services Director A copy of the original bill or invoice must accompany the voucher and be submitted to the I - CARE Business Office for payment processing

14. In emergency situations, participants may request assistance for food, household supplies, toiletries and / or other necessities (see 19. Financial Assistance for Other Necessities) In these instances, participants may be issued shopping cards for such and will be required to sign a pre - paid shopping card agreement Participants are required to return original receipts to Case Managers as proof of purchase Addit nal cards will not be issued without receipts from previous purchases Original receipts for purchases must be kept in the participant's file

15. Participants requesting assistance for car repairs must present two (2) estimates for repairs from a certified / licensed mechanic / shop Approval will be based on the severity of the situation and the practicality of the repair Financial assistance for car repairs will not exceed $ 500 per request

16. Participants requesting assistance for car insurance will be limited to one (1) monthly payment per program year Financial assistance for car insurance will not exceed $ 200 per request

17. Participants requesting assistance for public transportation (ICATS, Greenway, taxi services, etc.) will be based on the level of need on a case - by - case basis The Family Support Services Director must approve this request before submitting a letter of intent to the agency providing services

18. FINANCIAL ASSISTANCE FOR OTHER NECESSITIES a Clothing to attend job interviews, work, uniforms, special garments and shoes b School uniforms and supplies for children living in household of participant family c Child care assistance on a temporary basis d Other assistance as deemed appropriate to help participants to meet their goals to become self - sufficient

19. I - CARE is not obligated to meet any or all of the costs of any participant financial request

20. All supporting documentation must accompany the completed financial assistance application This includes but is not limited to pay stubs, course enrollment information, invoices, quotes, lease / rental agreements

21. If any information is missing or incomplete, the application will be returned for completion, potentially delaying the process for assistance

22. I - CARE, Inc. reserves the right to deviate from or make exceptions to these guidelines upon approval from the Executive Director

23. If I - CARE, Inc. has no unrestricted funds and assisting participants with other costs will not alleviate the burden, the agency can pay for civil / criminal penalties and fine / fees for an amount not to exceed $ 600 This payment would be a one - time benefit to the participant (If a participant exits and re - enters the program, they are not eligible to receive this type of service again)

APPLICATION INSTRUCTIONS

1. Fully complete the Request for Financial Assistance application including the calculation box on page 4, letters A through C, for the amount being requested

2. Complete the authorization to release information by stating the vendor to whom l - CARE is to release the notification of approved funding

3. No additional funding for the same request will be provided after I - CARE funding is approved if: A. other agencies have not fulfilled their approval of funds or changed their funding criteria ; B. the quote provided was not current ; C. items were missed in the quote ; D. additional items are required for equipment ; or, E. if another vendor / resource did not fund the anticipated amount on the quote

4. Sign and date the completed application Remember to keep a copy of the completed application for your own files

5. Funding approval is valid for 30 days from the date of approval

INDEMNIFICATION Participant (s) will indemnify and hold harmless I - CARE, Inc. and its employees from and against any and all expenses related to all claims, demands, liabilities, losses, costs, damages, actions, suits or other proceedings of any nature or kind whomsoever sustained, brought or prosecuted in any manner based upon, occasioned by or attributable to the negligent act or omissions or the willful or reckless misconduct of the vendor / contractor, in the fulfillment of utilizing the funds provided by I - CARE, Inc I - CARE, Inc. acts as a third party funder and as such has no role in prescribing, recommending equipment, selecting a vendor / contractor or in the relationship between the participant and vendor Payment from the I - CARE CSBG program is not a guarantee or warranty for the quality of work performed

Request for Financial Assistance Application
The level of funding assistance may vary based on the amount of the request and the availability of CSBG funds at the
time the request is received Complete one application per request

Calculation of Request for Financial Assistance (please complete by inserting funds received from other funding sources):

(Line A - B - C = D)

I understand and agree that I - CARE, Inc. may carry out inquiries for the purpose of confirming or clarifying the information submitted and processing the application with any other agency, company, or individual listed on this application form.  I further understand and agree that these inquiries may require exchange of information that may take the form of electronic data exchanges.  I certify that the information provided in the application is true, correct, and complete to the best of my knowledge and understand that falsification of information will be grounds for denial of this application and future financial assistance requests for up to one (1) year.

I will indemnify and hold harmless I - CARE, Inc. and its employees from and against any and all expenses related to all claims, demands, liabilities, losses, costs, damages, actions, suits or other proceedings of any nature or kind whomsoever sustained, brought or prosecuted in any manner based upon, occasioned by or attributable to the negligent act or omissions or the willful or reckless misconduct of the vendor / contractor, in the fulfillment of utilizing the funds provided by I - CARE, Inc.  I - CARE, Inc. acts as a third party funder and as such has no role in prescribing, recommending equipment, selecting a vendor / contractor or in the relationship between the participant and vendor.  Payment from the l - CARE CSBG program is not a guarantee or warranty for the quality of work performed.

Please review this form to ensure all information and supporting documentation is provided.  If any information is missing, the application will be returned for completion, resulting in a delay in processing the request.  Please keep a copy of the completed form for your files.

NOTE:  it is the participant's responsibility to follow up with the I - CARE CSBG program to ensure the application has been received.  If you have any questions about the application, or whether certain requests are eligible for funding, please do not hesitate to contact the CSBG Program at (704) 872-8141 or via any of the email addresses above.

FOR OFFICE USE ONLY

I - CARE CSBG Financial Assistance Application (revised version approved by BOD 2-28-19)