Request For Funds

Please Note: The child you are requesting funds for must be adjudicated dependent in Mohave County and all requests for funds must be pre-approved by the CASA Council. If you are requesting a clothing allowance, please make sure you have first checked with the DCS Case Manager to see if there are funds available.

If not, proceed with your request to CASA Council. If you are awarded funds you must provide a receipt for the goods or services purchased with those funds to the CASA Council. NO receipts means NO further request. Additionally, per form, please only submit your request and details for one child.

Request For Funds

Requester First And Last Name*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Shipping Address For Delivery*
Email Address*
Phone Number*
Child's First Name*
Age*
Please enter a number from 0 to 100.
Gender*
- Male
- Female
Amount Requested*
Requesting Agency (CASA, DCS, Foster Parent, Relative, Attorney, Other (Specify))*
Please submit detailed information on the reason for child's need (If request for clothing please note date of last clothing request.)*
Comments
This field is for validation purposes and should be left unchanged.

For any questions or concerns please contact
Beverly Siemens at (530) 632-5567.

Request For Funds

Request For Funds

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