Opioid Remediation Settlement Flex Funds Request Form

Completed by an agency/organization. Includes Flex Funds request and NBHS financial eligibility worksheet.

Submitted successfully.
Total Requested
$0.00
Entered request amounts
Remaining Under $1,000
$1,000.00
Within limit
Adjusted Income
$0.00
From worksheet

Requested Flex Funds

Max $1,000

Select the category and specific item being requested, then enter the amount needed. Use a separate line for each expense. The total request cannot exceed $1,000.

Monthly Income
$0.00
Annual ÷ 12
Allowable Liabilities
$0.00
Caps applied
Adjusted Income
$0.00
Income minus liabilities
Submitted requests route to Elevita for review by Region 5 Systems.
Select "Next" to fill out the financial eligibility form and submit the application.