Request for Service - Illinois Department of Commerce & Economic Opportunity

Request for Service - Illinois Department of Commerce & Economic Opportunity

Assistance being requested (Select all that apply)

Note: Funding for energy assistance has been exhausted at this time. On October 1 the LIHEAP program will reopen for older adults, individuals with a disability, families with at least one child under the age 5 and disconnected/imminent disconnected households. All others households can apply beginning in November.

Housing Assistance (Rent or other housing related)

Weatherization (Home Energy Efficiency Improvements)

Are there other services you need?

All of these services may not be available in your county. When your local agency contacts you they will discuss your request and assist you with the services they provide.

Select

Transportation Assistance

Post Secondary Education Support

Medical/Dental/Hearing/Vision/Prescription Assistance

K-12 Educational Assistance

Child Care Assistance

Adult Literacy/Education Classes

Financial Management Programs

Information on Household Member(s)

First Name (Head of Household - HOH)*

Middle Initial (HOH)

Social Security Number/ITIN Number (HOH)*

All income-qualified residents of Illinois can receive bill assistance. The entire nine-digit Social Security Number or ITIN must be provided. (Households with individuals without an SSN or ITIN are still eligible but must apply at a Partner Intake Site. For a list of Partner Intake Sites, please visit: www.CEDAorg.net/sites)

Date of Birth (HOH)*

Enter "None" if there is no access to email.*

Ethnicity (HOH)

Select or enter value

Emancipated minor legally separated from parents

Income Sources for HOH (Select all that apply)

Please count all GROSS income in your house for the past 30 days. Our specialists will further evaluate what is and isn't counted during your phone interview.

Select

Monthly Income (HOH) - Wages/Salary

Monthly Income (HOH) - Social Security Income SSI

Monthly Income (HOH) - Soc. Sec. Disability SSD

Monthly Income (HOH) - TANF Cash

Monthly Income (HOH) - Unemployment

Monthly Income (HOH) - Worker's Compensation

Monthly Income (HOH) - VA Disability

Monthly Income (HOH) - AABD Cash

Monthly Income (HOH) - Other (List and describe)

Additional Household Member(s) (if applicable)

Household Member #2 (if applicable)

First Name (Household Member #2)

Middle Initial (Household Member #2)

Last Name (Household Member #2)

Relationship to Head of Household (Household Member #2)

Select

Social Security Number/ITIN Number (Household Member #2)

Date of Birth (Household Member #2)

Race (Household Member #2)

Select

Ethnicity (Household Member #2)

Select

Emancipated minor (Household Member #2)

Disabled (Household Member #2)

Veteran (Household Member #2)

Income Sources for HM #2 (Select all that apply)

Please count all GROSS income in your house for the past 30 days. Our specialists will further evaluate what is and isn't counted during your phone interview.

Select

Monthly Income (HM #2) - Wages/Salary

Monthly Income (HM #2) - Soc. Security Income SSI

Monthly Income (HM #2) - Soc. Sec. Disability SSD

Monthly Income (HM #2) - TANF Cash

Monthly Income (HM #2) - Unemployment

Monthly Income (HM #2) - Worker's Compensation

Monthly Income (HM #2) - VA Disability

Monthly Income (HM #2) - AABD Cash

Monthly Income (HM #2) - Other (List and describe)

Household Member #3 (if applicable)

First Name (Household Member #3)

Middle Initial (Household Member #3)

Last Name (Household Member #3)

Relationship to Head of Household (Household Member #3)

Select

Social Security Number/ITIN Number (Household Member #3)

Date of Birth (Household Member #3)

Race (Household Member #3)

Select

Ethnicity (Household Member #3)

Select

Emancipated minor (Household Member #3)

Disabled (Household Member #3)

Veteran (Household Member #3)

Income Sources HM #3 (Select all that apply)

Please count all GROSS income in your house for the past 30 days. Our specialists will further evaluate what is and isn't counted during your phone interview.

Select or enter value

Monthly Income (HM #3) - Wages/Salary

Monthly Income (HM #3) - Soc. Security Income SSI

Monthly Income (HM #3) - Soc. Sec. Disability SSD

Monthly Income (HM #3) - TANF Cash

Monthly Income (HM #3) - Unemployment

Monthly Income (HM #3) - Worker's Compensation

Monthly Income (HM #3) - VA Disability

Monthly Income (HM #3) - AABD Cash

Monthly Income (HM #3) - Other (List and describe)

Household Member #4 (if applicable)

First Name (Household Member #4)

Middle Initial (Household Member #4)

Last Name (Household Member #4)

Relationship to Head of Household (Household Member #4)

Select

Social Security Number/ITIN Number (Household Member #4)

Date of Birth (Household Member #4)

Race (Household Member #4)

Select

Ethnicity (Household Member #4)

Select

Emancipated minor (Household Member #4)

Disabled (Household Member #4)

Veteran (Household Member #4)

Income Sources HM #4 (Select all that apply)

Please count all GROSS income in your house for the past 30 days. Our specialists will further evaluate what is and isn't counted during your phone interview.

Select

Monthly Income (HM #4) - Wages/Salary

Monthly Income (HM #4) - Soc. Security Income SSI

Monthly Income (HM #4) - Soc. Sec. Disability SSD

Monthly Income (HM #4) - TANF Cash

Monthly Income (HM #4) - Unemployment

Monthly Income (HM #4) - Worker's Compensation

Monthly Income (HM #4) - VA Disability

Monthly Income (HM #4) - AABD Cash

Monthly Income (HM #4) - Other (List and describe)

Household Member #5 (if applicable)

First Name (Household Member #5)

Middle Initial (Household Member #5)

Last Name (Household Member #5)

Relationship to Head of Household (Household Member #5)

Select

Social Security Number/ITIN Number (Household Member #5)

Date of Birth (Household Member #5)

Race (Household Member #5)

Select

Ethnicity (Household Member #5)

Select

Emancipated minor (Household Member #5)

Disabled (Household Member #5)

Veteran (Household Member #5)

Income Sources HM #5 (Select all that apply)

Please count all GROSS income in your house for the past 30 days. Our specialists will further evaluate what is and isn't counted during your phone interview.

Select

Monthly Income (HM #5) - Wages/Salary

Monthly Income (HM #5) - Soc. Security Income SSI

Monthly Income (HM #5) - Soc. Sec. Disability SSD

Monthly Income (HM #5) - TANF Cash

Monthly Income (HM #5) - Unemployment

Monthly Income (HM #5) - Worker's Compensation

Monthly Income (HM #5) - VA Disability

Monthly Income (HM #5) - AABD Cash

Monthly Income (HM #5) - Other (List and describe)

If there are more than 6 household members your local agency will take the additional information on a later phone call.

Household Member #6 (if applicable)

First Name (Household Member #6)

Middle Initial (Household Member #6)

Last Name (Household Member #6)

Relationship to Head of Household (Household Member #6)

Select

Social Security Number/ITIN Number (Household Member #6)

Date of Birth (Household Member #6)

Race (Household Member #6)

Select

Ethnicity (Household Member #6)

Select

Emancipated minor (Household Member #6)

Disabled (Household Member #6)

Veteran (Household Member #6)

Income Sources HM #6 (Select all that apply)

Please count all GROSS income in your house for the past 30 days. Our specialists will further evaluate what is and isn't counted during your phone interview.

Select

Monthly Income (HM #6) - Wages/Salary

Monthly Income (HM #6) - Soc. Security Income SSI

Monthly Income (HM #6) - Soc. Sec. Disability SSD

Monthly Income (HM #6) - TANF Cash

Monthly Income (HM #6) - Unemployment

Monthly Income (HM #6) - Worker's Compensation

Monthly Income (HM #6) - VA Disability

Monthly Income (HM #6) - AABD Cash

Monthly Income (HM #6) - Other (List and describe)

Street Address (Line 1)*

Street Address (Line 2 - if necessary)

Mailing Address (if different from Street Address)

Mailing Address (Line 1)

Mailing Address (Line 2)

Household Information

Are your electric and gas included in your rent?

Select

Dwelling type

Select

Primary Utility Information (if requesting utility assistance)

What is the name of the company that you pay to heat your residence?*

Select or enter value

Name appearing on primary utility bill

Account number on primary utility bill

Current amount owed to primary utility

Do you have a past due notice for primary utility?

Select

Are you disconnected or have you received a disconnect notice?

Select

Secondary Utility Information (If applicable)

Do you pay a different a company than the one given in the previous answer for electricity?

Select

Name of secondary utility

Select or enter value

Name appearing on secondary utility bill

Account number of secondary utility

Current amount owed to secondary utility

Do you have a past due amount for secondary utility

Select

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Assistance being requested (Select all that apply)

Information on Household Member(s)

Additional Household Member(s) (if applicable)

Service Address

Household Information

Primary Utility Information (if requesting utility assistance)

Secondary Utility Information (If applicable)

Notes and Comments