The Angelo Militello DCFS Emergency Fund

The LAN41 and ECA value the effort and resources you have already devoted to understanding and assessing the needs of this family. We make the following assumptions: a needs assessment is complete; eligibility reviewed for other resources such as unemployment benefits, Medicaid, and SNAP; discussion about community supports have been discussed, recommended and referrals made, where needed. The purpose of this form is to gather basic data about each family receiving emergency wrap-around funds for resource management.

 
 

Organization Information

 
 
 
 

 

Family Information

 
 
 
 
 
 

 

Include the age of the child receiving support

 
mm/dd/yyyy
 

Select all that apply

 

Check all that apply

 

 

Mark, "None," if residency is not verified or unable to be verified. Verification examples: driver's license, state ID, utility bill, lease, mortgage statement, or other valid form. Enter address here to confirm residency in Niles Township: https://www.cookcountyassessor.com/address-search

 

 

Wraparound Request Information

 
 
 
 
 
 
 

Include a list of other services the family has already accessed for support.

 
 
 
 

Please complete a release of information for the primary caregiver and attach here by uploading the document. If requesting camp payment, rental or utility assistance upload a statement or bill.

Drop your files here