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2. FY26 Story County ASSET Claim
4. Agency*
   -- Select One --ACCESSACPC (Ames Comm Preschool)Boys and Girls Club of Story CountyCamp FireCCJ (Center for Creative Justice)ChildServeGNEA (Good Neighbor)HIRTA (Heart of Iowa Transit Agency)Heartland of Story CountyLegal Aid of Story CountyLSI (Lutheran Services)MGMC (Mary Greely Medical Center)MICA (Mid-Iowa Community)PFCC (Prairie Flower Children's Center)PHC (Primary Health Care)Raising ReadersRSVP (Central IA Retired Senior Volunteer)STCC (Story Time Child Care)The Community AcademyTSA (Salvation Army)UCC (University Community Center)YSS
5. Month*
   -- Select One --JulyAugustSeptemberOctoberNovemberDecemberJanuaryFebruaryMarchAprilMayJune (Estimate) Due 1st Tues. of JuneJune (Actual)
7. June (Actual)
   -- Select One --No Changes (Still Attach Claim & Invoice)Changes

   Please submit by the last Friday of July

9. Agency Contact Name*
10. Email Adress*
12. Claim and Invoices*

    *all claims and invoices must be signed

14. My Agency's SCORECARD is up to date*

    1. Yes
    2. No
16. If Mental Health Service (for Story County only), it is not included*

    1. Yes
    2. No
    3. N/A
18. THANK YOU FOR SUBMITTING.

    Payment may be delayed for incorrect claim(s). If you have any questions, please contact Sandra King, Director of External Operations and County Services at 515-382-7243 or Joy Cory, Administrative Assistant at 515-382-7208.

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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field