Opioid Settlement Online Request Form

Opioid Settlement Online Request Form

Use the form below to request funding from Wyoming County’s opioid settlement funds. Applications are reviewed by the Wyoming County Opioid Settlement Committee.

The application asks for your organization’s contact information and Federal Identification Number (EIN), the project name, the total amount requested, the expected program start date, a project narrative, how the project will reduce substance use, how you will evaluate its outcome, and a detailed budget proposal. You may also attach supporting documents.

Apply Online

Primary Contact Person *

Number Federal Total

Email *

Phone Number *

Fax Number

Address *

Address Line 1

Address Line 2

City

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Zip Code

Federal Identification Number (EIN)

Project Name *

Total Amount Requested *

Expected Program Start Date *

Project Narrative *

Reducing Opioid Use *

Project Evaluation

Budget Proposal *

Upload Supporting Documents

Drag & Drop Files, Choose Files to Upload

Submit Application