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English (US)
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FINANCIAL ASSISTANCE APPLICATION
To Be Eligible, You must be an Illinois Resident. You will have to provide the following (1) Proof of ID for all household members; (2) Proof that you live in Illinois; (3) Proof of Household Income;
Hello! Welcome! Bienvenue! Akwabba! How did you hear about United African Organization?
Family Member
Friend
Online Search
Community Organization
Radio
Other
Staff completing intake
*
Tsion
Mamadou
Tresor
Other
Please tell us your Name
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First Name
Last Name
Address
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Street Address & Apt/ Unit #
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the address provided a shelter's address ?
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YES
NO
What's your Phone Number?
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-
Area Code
Phone Number
Alternate phone number
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-
Area Code
Phone Number
What's your Email address?
example@example.com
Tell us your Gender
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Male
Female
Other
Date of Birth
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-
Month
-
Day
Year
Your Birthday
Country of Birth
*
What languages do you speak?
What's your Ethnicity?
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Black/African/Caribbean/African American
Asian
American Indian
Alaska Native
Hawaiian
White
Prefer not to say
Other
Race
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Non Hispanic
Hispanic
Prefer not to say
What's your Marital Status?
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Single
Married
Widowed
Divorced
Separated
Tell us about your family living together here. What's your household size? Including yourself, please tell us how many people are in each age group
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# of Children (0 - 18 years)
# of Adults (19 - 64 years)
# of Seniors (65+)
Tell us a little more about yourself. List of You + Individuals in your household
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First Name
Last Name
Relationship to You
Date of Birth
Current Income
Has a Disability?
Phone Number (if over 18 years)
1
2
3
4
5
6
7
8
What kind of Work do you do?
*
If you do not work say "Unemployed"
My monthly income
*
Date of Arrival to United States
*
Have you received any other covid relief grants?
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YES, $1000
YES, $1,500/ $2,000
YES, $3,000/$4,000
NO
What is your current financial need?
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(include COVID-related issues, such as a family member got COVID-19, a family member passed away during the pandemic, I have $0 income, reduced income etc.)
Do you or someone in your household receive any of these benefits?
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YES
NO
Link Card
Medicaid
Unemployment Benefits
IRS Stimulus Payment
Housing Status
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I own my home
I rent my home
I stay with someone
I'm homeless
Other
I have NOT received (Please select all that apply)
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Federal Stimulus Package under the CARES Act
Unemployment Insurance through the Illinois Department of Employment Security
Public Benefits such as SNAP, MEDICAID, TANF among others.
Emergency Support Funds received will be used for: (please check all that apply) :
*
Food and basic supplies
Utility bills assistance
Medication or Medical Co Pay Assistance
Rental Assistance
Other Financial Assistance
What is your highest level of education?
No formal education completed
Completed some primary school
Completed primary school
Completed some secondary school
Completed secondary school
Completed some college
Completed college/bachelor's education
Beyond bachelor's degree
Prefer not to say
Does anyone in your household have a disability? If yes, Please specify who
Do you have any English proficiency? Check all that apply.
Reading
Writing
Speaking
Please briefly describe any job training or experience you have.
Is any member of your household currently a Lawful Permanent Resident or a United States Citizen?
Yes
No
Date of Exit from Haiti (When did you most recently leave Haiti?)
Most recent residence in Haiti. Prior to leaving the country, where in Haiti did you most recently reside?
Upload Your ID for all Household Members Here
Browse Files
TVDL, Chicago City Key, Passport, State ID, Drivers License, selfie etc
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of
Upload Your Proof of Address Here (should be dated within the last 6 months)
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Bill, ID with current address, Lease, Bank Statement, Hospital Bill, Letters
Cancel
of
Upload your Proof of Income all Household Members Here
Browse Files
Paystub, Tax Returns, Income Statement
Cancel
of
Upload hardship proof here
Browse Files
Medical bills, loss of job
Cancel
of
I swear or affirm that the information I have provided here is true and correct to the best of my personal knowledge and belief. Please Sign below:
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