Good Neighbor Fund

Good Neighbor Fund (GNF)
Emergency Financial Assistance for San Miguel, Ouray & West End Montrose and Rico Communities 

The Good Neighbor Fund (GNF) provides emergency financial support to individuals and families who live or work in San Miguel, Ouray County, Rico or the West End of Montrose County and are facing a short-term crisis. This fund exists to help our community members remain housed, employed, and stable during difficult times. 

Who Can Apply? 

To qualify for the Good Neighbor Fund, applicants must: 

• Live or work in San Miguel, Ouray, Rico or the West End of Montrose County for at least one full year 

• Be currently or recently employed 

• Be experiencing a non-recurring and unexpected financial hardship 

• Have exhausted other available resources 

• Show a plan for maintaining stability moving forward 

• Have not received a GNF grant in the past 12 months 

What Can GNF Help With? 

• Applicants may receive up to $2,500 every 12 months to help with unexpected emergency needs, including: 

• Rent or mortgage 

• Utility bills 

• Car repairs 

• Medical bills 

• Food or other essential expenses 

Application Requirements

• Demonstrated Hardship: Applicants must show financial distress caused by an unexpected, non-recurring crisis.
• Exhaustion of Resources: Documentation showing that all other available financial resources have been utilized.
• Sustainability Plan: A clear explanation of how the household intends to maintain financial stability moving forward.
• Required Documentation: Lease / Mortgage, Proof of Employment, Bank Statement
  • If you are unable to upload the required documents in the application form below, please email them directly to gnf@tchnetwork.org.

Please Review the Qualification Criteria

• Good Neighbor Fund – Emergency Response Grant Qualification Criteria
• Fondo de Good Neighbor ‐ Respuesta a Emergencias Criterios de calificación de la subvención

Please enable JavaScript in your browser to complete this form.

Name: *

First

Middle

Last

Email: *

Date of Birth: *

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Are you married or living with a significant other?

• Yes
• No

If yes, spouse/partner’s name:

First

Middle

Last

Number of children living in the household? *

Ages:

Physical Address: *

Address Line 1

Address Line 2

City

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Zip Code

Mailing Address same as Physical Address:

• Yes
• No

Mailing Address:

Address Line 1

Address Line 2

City

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Zip Code

Primary Phone: *

Secondary Phone:

Length of time living or working in San Miguel County, West end of Montrose, or Ouray County: *

Do you plan to stay in the area once this crisis is over? *

• Yes
• No

Race: *

• White
• Black or African American
• American Indian or Alaskan Native
• Asian
• Native Hawaiian or other Pacific Islander
• Other (please specify):

Race: Other (please specify):

Stress for other

Country of Origin: *

• US Born
• Immigrant

Ethnicity: *

• Hispanic or Latino
• Not Hispanic or Latino

Gender: *

• Male
• Female
• Transgender Male
• Transgender Female
• Gender non-conforming
• Nonbinary
• Other gender identity

Requested Amount: *

Max amount is $2500

What are you requesting funds for? *

Is your application connected to a current challenge with substance use - either your own or that of someone in your household? *

• Yes
• No

Please describe in detail why you are in this crisis: *

Have you (or your spouse/partner) applied to GNF or OCRF in the past? *

• Yes
• No

If YES,

Date of Requested:

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Amount Requested:

Are you currently employed?

• Yes
• No

What date did unemployment begin?

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Have you applied for unemployment benefits?

• Yes
• No

What date did you submit your unemployment application?

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Were you approved for unemployment benefits?

• Yes
• No

What date did your unemployment benefits started or will start:

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Amount of unemployment benefits you were approved to receive each month:

Most Recent Employer:

Name of Company or Self employed:

Employer City:

Employer State:

Manager Name:

Manager Phone:

Do you plan to return to this employer?

• Yes
• No

Return Date to Employer:

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Is a medical release required for your return?

• Yes
• No

What is the anticipated date of the medical release?

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Do you have a new job lined up?

• Yes
• No

If new job lined up,

Anticipated start date:

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Name of new company

New Company Address

Address Line 1

Address Line 2

City

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Zip Code

New Manager Name:

New Manager Phone Number:

What are your sources of monthly income? (* Proof of income sources required) Enter 0 if not applicable.

Former Monthly Employment* (salaries, tips, bonuses, etc.) *

Current Monthly Employment* (salaries, tips, bonuses, etc.) *

Alimony/Child Support *

Amount Social Security/Retirement/Disability* *

Welfare/TANF/Food Assistance(SNAP) *

Trust Funds/Annuities/Interest *

Severance Pay *

Lottery Winnings/Insurance Settlements, etc *

What are your monthly expenses? Please provide documentation of these expenses when you submit your application. Enter 0 if not applicable.

Rent/Mortgage *

Utilities (electric, water/sewer, gas) *

Cell Phone/Phone *

Food *

Health and Medical Bills (insurance, prescriptions) *

Car-Related Payments (car insurance, gas, car payment) *

Childcare *

Child Support/Alimony *

Other *

What other resources have you pursued? You must provide an answer for each (approved, terminated, denied etc.)

Housing Authority Section 8 Rental Assistance/HUD/etc... *

• Yes
• No

Housing Authority Section 8 Rental Assistance/HUD/etc... *

Social Security/Disability/etc… *

• Yes
• No

Social Security/Disability/etc… *

Social Services TANF *

• Yes
• No

Social Services TANF *

Food Stamps/SNAP… *

• Yes
• No

Food Stamps/SNAP… *

Medicaid/CHP+ *

• Yes
• No

Medicaid/CHP+ *

Emergency Funds *

• Yes
• No

Emergency Funds *

Health Insurance *

• Yes
• No

Health Insurance *

Private Charities *

• Yes
• No

Private Charities *

Family/Friends *

• Yes
• No

Family/Friends *

Victim’s Compensation *

• Yes
• No

Victim’s Compensation *

Other

• Yes
• No

Other

How much cash do you have on-hand (including checking/savings accounts*)? *Proof of account balance required *

Please explain how you have exhausted all your other resources: *

If you are reapplying to GNF or OCRF, elaborate on what steps and actions you have taken to become financially stable since you last received funding. *

Please provide us with any other information that you feel would help in determining your eligibility for funds *

Social Determinants of Health Questionnaire:

What is your living situation? *

• I have a steady place to live.
• I have a place to live, but I am worried about losing it in the future.
• I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, a bench, in a car, abandoned building, bus or train station, or in a park.
• I choose not to answer

Think about the place you live. Do you have problems with any of the following? (select all that apply). *

• Pests such as bugs, ants or mice
• Smoke detectors missing or not working
• Oven or stove not working
• Mold
• Lead paint or pipes
• Lack of heat
• None of the above

Within the past 12 months, you worried that your food would run out before you got money to buy more: *

• Often true
• Sometimes true
• Never true
• I choose not to answer

Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more: *

• Often true
• Sometimes true
• Never true
• I choose not to answer

In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting to things needed for daily living (food, job interview, child care)? *

• Yes
• No
• I choose not to answer

In the past 12 months has the electric, gas, oil, or water company threatened to shut of services in your home of where you live? *

• Yes
• No
• I choose not to answer

If yes, is it currently shut off?

• Yes
• No

Do problems getting child care make it difficult for you to work or study? *

• Yes
• No
• I choose not to answer

How many times have you received care in an emergency room (ER) over the last 12 months? *

• 0 times
• 1 time
• 2 or more times
• I choose not to answer

In the last 12 months, have you needed to see a medical provider (doctor, dentist, mental health, optometrist, specialist), but could not because of how much it cost? *

• Yes
• No
• I choose not to answer

How often do you have a problem understanding what is told to you by a medical provider about your health or medical condition? *

• Never
• Rarely
• Sometimes
• Fairly often
• Frequently
• I choose not to answer

How confident are you in filling out medical forms by yourself? *

• Extremely confident
• Somewhat confident
• A little bit confident
• Not at all confident
• I choose not to answer

How often does anyone, including family and friends, insult or talk down to you? *

• Never
• Rarely
• Sometimes
• Fairly often
• Frequently
• I choose not to answer

How often does anyone, including family and friends, scream or curse at you? *

• Never
• Rarely
• Sometimes
• Fairly often
• Frequently
• I choose not to answer

How often does anyone, including family and friends, threaten you with harm? *

• Never
• Rarely
• Sometimes
• Fairly often
• Frequently
• I choose not to answer

How often does anyone, including family and friends, physically hurt you? *

• Never
• Rarely
• Sometimes
• Fairly often
• Frequently
• I choose not to answer

In the past 12 months, how often do you participate in group activities like going to church, volunteering, attending a meeting or an organized group (book club, Rotary, veterans ‘group)? *

• Never
• Rarely
• Sometimes
• Fairly often
• Frequently
• I choose not to answer

If your family suddenly had a crisis or needed money for an unexpected expense, like a car repair or serious illness, would you have someone you could count on for help? *

• Yes
• No
• I choose not to answer

How often do you feel lonely or isolated from those around you? *

• Never
• Rarely
• Sometimes
• Fairly often
• Frequently
• I choose not to answer

Stress is when someone feels tense, nervous, anxious or can’t sleep at night because their mind is troubled. How stressed are you? *

• Not at all
• Slightly stressed
• Moderately stressed
• Very stressed
• I choose not to answer

If your family suddenly had a crisis or needed money for an unexpected expense, like a car repair or serious illness, would you have someone you could count on for help? (copy) *

• Yes
• No
• I choose not to answer

Upload Instructions

If the uploads are too big, please email lease/mortgage, proof of employment, and bank statement to gnf@tchnetwork.org.

Upload Proof of Employment Here (Paystubs, offer letter, etc.):

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Current in the last 60 days.

Upload Copy of Lease Agreement or Mortgage Statement Here:

Drag & Drop Files, Choose Files to Upload

Current in the last 60 days.

Upload Bank Statement showing current cash on hand:

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Current in the last 60 days.

Upload copies of the bill/s that you are requesting help with.

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Current in the last 60 days.

Release of Information

If you are applying for rental or mortgage assistance, please complete the Release of Information (ROI). This allows our team to speak directly with your landlord, property manager, mortgage company, or funder to verify required information and help prevent delays in processing your application.

I, the tenant of

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

hereby consent to the Landlord or Property Management Company staff sharing my personal tenancy information with the representative of the of Tri-County Health Network in regard to the Good Neighbor Fund or Ouray County Response Fund.

This information may include, but is not limited to, residency status and rent amount.

Tenant Name *

Date *

Good Neighbor Fund Representative

Date

If you have any issues uploading you can email attachments directly to GNF@tchnetwork.org.

Please be sure to include your name in the email.  

Attestation:
I certify that the information given on this application is accurate and complete to the best of my knowledge and belief. I also understand that false statements or information are grounds for denial of assistance and/or prosecution of fraud, as allowed by Colorado law.

Release of Information Consent
By signing this application, I understand that my information may include protected health information. I authorize the release of my information to any person or agency necessary to meet my service needs, including, but not limited to, vendors and partner agencies. This information will be used solely for the purpose of assessing, arranging, and meeting my individual service needs.

I release Tri-County Health Network and its partners from any liability related to the sharing of this information.

Applicant Signature: *

Clear Signature

Applicant Signature Date: *

Submit

Need Help or Have Questions? 

Our team is here to help you through the process. 
Call or text: 970-708-7096 
Email: GNF@tchnetwork.org