Date
Date
Name *
Name
Sex *
Address. If homeless, state "homeless" *
Address. If homeless, state "homeless"
Sources of Income
Living Situation
Gas, Electric, Phone, Water, Car payment, Car insurance, etc.
Other Assistance Applied for
If applicable, describe the following assistance, for which you have applied. Examples : Medicare/ Medicaid, Fuel assistance, Social Security Disability, aid from the Town Welfare Office, aid from the Veteran’s Administration
By choosing "yes" you acknowledging this serves as an electronic signature until a physical one can be obtained

* PLEASE READ * All applicants requesting assistance with rent,mortgage, and/or utilities WILL be required to provide sufficient documentation as requested by Almost Home Chicago. Valid driver's license or state ID will be required to receive assistance with rent, mortgage, and/or utilities, as well as for other services as determined by Almost Home Chicago. Your ID must reflect your residence in one of our service areas. We may request proof of current financials to determine eligibility for services. A completed application must be submitted before any request for assistance is considered. 

*HOMELESS CLIENTS * Requirements for completion of application process will be determined on a case by case basis.