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.

Today's Date*

Organization Information

Entity making request (Organization)*

Select or enter value

Name of person making request (Organization)*

Email address of person making request (Organization)*

Family Information

First Name (Family)*

Last Name (Family)*

Address (Family, street and number)*

City (Family)*

Zip Code (Family)*

Child's birthdate

Include the age of the child receiving support

Basic income verification (Family)*

Select all that apply

Select or enter value

Vulnerability or at-risk factors

Check all that apply

Select

Check if Niles Township residency is verified*

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

Yes, Niles Township resident

No, not Niles Township resident

None, not verified

Wraparound Request Information

Request type*

Select or enter value

Amount requested*

Specific Use of Funds*

Describe recent hardship and need for funds*

Other notes

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

Payment to be made to (name & mailing address)*

File Upload

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.

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