Normal Township General and Emergency Assistance Application

1
What is your name?* This field is required.
First Name
Middle Name
Last Name
Suffix
2
What is your date of birth?* This field is required.
Date
Month
Day
Year
3
What is your address?* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
What is your email address?* This field is required.
example@example.com
5
What is your mobile phone number?* This field is required.
Area Code
Phone Number
6
If you have a home / alternate phone number, please enter it below:
Area Code
Phone Number
7
Do you have a Social Security number?* This field is required.
Yes
No
8
What is your marital status:* This field is required.
Married, Living Together
Married, Living Separately
Single, Never Married
Divorced
Domestic Partner
Separated
Widowed
Other
9
What is your gender:* This field is required.
Female
Male
Transgender
Non-binary
Agender
Other
Prefer not to respond
10
What is your race / ethnicity:* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Multi-Racial
Prefer not to respond
11
What is your primary language?* This field is required.
English
Spanish
French
Other
12
Are you a U.S. Citizen?* This field is required.
Yes
No
13
Are you a legal resident?* This field is required.
Yes
No
14
Is your crisis or loss of income related to COVID-19?* This field is required.
Yes
No
15
When did your crisis or loss of income begin?* This field is required.
Within the last 30 days
Within the last 60 days
Within the last 90 days
16
Please describe your crisis or reason for loss of income:* This field is required.
17
Which type of assistance are you requesting?* This field is required.
Rental / Mortgage
Water
Natural Gas
Electric
Transportation
Medical / Medication
Other
18
Special Status - Please check all that apply:
I am homeless
I am fleeing domestic violence
I am a Veteran
I am a senior citizen
I live in subsidized / supportive housing
Other
19
Household Income & Assets* This field is required. Please detail below the combined monthly gross income from each source earned by all persons 18+ or older for the past 30 days living in your household. Enter "0" if no income is earned from the source listed.
$
Part-Time Employment
Row 0, Column 0
Full-Time Employment
Row 1, Column 0
Self-Employment
Row 2, Column 0
Unemployment
Row 3, Column 0
SSDI
Row 4, Column 0
SSA
Row 5, Column 0
Veteran's Benefits
Row 6, Column 0
Child Support
Row 7, Column 0
Pension
Row 8, Column 0
Worker's Compensation
Row 9, Column 0
Bank Accounts (current balance of all bank accounts)
Row 10, Column 0
Cash on Hand (total of cash on hand among all persons in household)
Row 11, Column 0
Other Income Source
Row 12, Column 0
TOTAL
Row 13, Column 0
Part-Time Employment
Full-Time Employment
Self-Employment
Unemployment
SSDI
SSA
Veteran's Benefits
Child Support
Pension
Worker's Compensation
Bank Accounts (current balance of all bank accounts)
Cash on Hand (total of cash on hand among all persons in household)
Other Income Source
TOTAL
$
Row 0, Column 0
$
Row 1, Column 0
$
Row 2, Column 0
$
Row 3, Column 0
$
Row 4, Column 0
$
Row 5, Column 0
$
Row 6, Column 0
$
Row 7, Column 0
$
Row 8, Column 0
$
Row 9, Column 0
$
Row 10, Column 0
$
Row 11, Column 0
$
Row 12, Column 0
$
Row 13, Column 0
1 of 14
20
Household Benefits* This field is required. Please detail below the combined amount of benefits from the sources listed below earned by all persons 18+ or older for the past 30 days living in your household. Enter "0" if no benefit is received from the source listed.
$
MCCA
Row 0, Column 0
COB Township
Row 1, Column 0
Normal Township
Row 2, Column 0
PATH
Row 3, Column 0
Salvation Army
Row 4, Column 0
SNAP
Row 5, Column 0
TANF
Row 6, Column 0
LIHEAP
Row 7, Column 0
WIC
Row 8, Column 0
AABD
Row 9, Column 0
RSDI
Row 10, Column 0
SSI
Row 11, Column 0
Other
Row 12, Column 0
TOTAL
Row 13, Column 0
MCCA
COB Township
Normal Township
PATH
Salvation Army
SNAP
TANF
LIHEAP
WIC
AABD
RSDI
SSI
Other
TOTAL
$
Row 0, Column 0
$
Row 1, Column 0
$
Row 2, Column 0
$
Row 3, Column 0
$
Row 4, Column 0
$
Row 5, Column 0
$
Row 6, Column 0
$
Row 7, Column 0
$
Row 8, Column 0
$
Row 9, Column 0
$
Row 10, Column 0
$
Row 11, Column 0
$
Row 12, Column 0
$
Row 13, Column 0
1 of 14
21
Household Expenses* This field is required. Please detail the total spent monthly for each of the household expense categories listed below. Enter "0" if there is no expense incurred for that category.
$
Rent / Mortgage
Row 0, Column 0
Food
Row 1, Column 0
Cable TV / Internet
Row 2, Column 0
Electric
Row 3, Column 0
Natural Gas
Row 4, Column 0
Water
Row 5, Column 0
Insurance
Row 6, Column 0
Loans / Credit
Row 7, Column 0
Vehicle
Row 8, Column 0
Other
Row 9, Column 0
TOTAL
Row 10, Column 0
Rent / Mortgage
Food
Cable TV / Internet
Electric
Natural Gas
Water
Insurance
Loans / Credit
Vehicle
Other
TOTAL
$
Row 0, Column 0
$
Row 1, Column 0
$
Row 2, Column 0
$
Row 3, Column 0
$
Row 4, Column 0
$
Row 5, Column 0
$
Row 6, Column 0
$
Row 7, Column 0
$
Row 8, Column 0
$
Row 9, Column 0
$
Row 10, Column 0
1 of 11
22
Additional Household Members: 1 of 8If you do not have additional household members you may skip ahead by clicking "NEXT" to complete your application. For each additional member of your household, please provide information in the following format (use commas to separate): FIRST NAME, MIDDLE INITIAL, LAST NAME, DATE OF BIRTH, AGE, RELATIONSHIP TO APPLICANT, GENDER
23
Additional Household Members: 2 of 8For each additional member of your household, please provide information in the following format (use commas to separate): If you do not have additional household members you may skip ahead by clicking "NEXT" to complete your application. FIRST NAME, MIDDLE INITIAL, LAST NAME, DATE OF BIRTH, AGE, RELATIONSHIP TO APPLICANT, GENDER
24
Additional Household Members: 3 of 8For each additional member of your household, please provide information in the following format (use commas to separate): If you do not have additional household members you may skip ahead by clicking "NEXT" to complete your application. FIRST NAME, MIDDLE INITIAL, LAST NAME, DATE OF BIRTH, AGE, RELATIONSHIP TO APPLICANT, GENDER
25
Additional Household Members: 4 of 8For each additional member of your household, please provide information in the following format (use commas to separate): If you do not have additional household members you may skip ahead by clicking "NEXT" to complete your application. FIRST NAME, MIDDLE INITIAL, LAST NAME, DATE OF BIRTH, AGE, RELATIONSHIP TO APPLICANT, GENDER
26
Additional Household Members: 5 of 8For each additional member of your household, please provide information in the following format (use commas to separate): If you do not have additional household members you may skip ahead by clicking "NEXT" to complete your application. FIRST NAME, MIDDLE INITIAL, LAST NAME, DATE OF BIRTH, AGE, RELATIONSHIP TO APPLICANT, GENDER
27
Additional Household Members: 6 of 8For each additional member of your household, please provide information in the following format (use commas to separate): If you do not have additional household members you may skip ahead by clicking "NEXT" to complete your application. FIRST NAME, MIDDLE INITIAL, LAST NAME, DATE OF BIRTH, AGE, RELATIONSHIP TO APPLICANT, GENDER
28
Additional Household Members: 7 of 8For each additional member of your household, please provide information in the following format (use commas to separate): If you do not have additional household members you may skip ahead by clicking "NEXT" to complete your application. FIRST NAME, MIDDLE INITIAL, LAST NAME, DATE OF BIRTH, AGE, RELATIONSHIP TO APPLICANT, GENDER
29
Additional Household Members: 8 of 8For each additional member of your household, please provide information in the following format (use commas to separate): If you do not have additional household members you may skip ahead by clicking "NEXT" to complete your application. FIRST NAME, MIDDLE INITIAL, LAST NAME, DATE OF BIRTH, AGE, RELATIONSHIP TO APPLICANT, GENDER
30
Client SignatureI have read this application and declare under penalties of perjury that, to the best of my knowledge and belief, the information supplied in this application and all accompanying statements is true and correct, and that it is a complete statement of all income, assets or resources belonging to me or to any member of my immediate family.
Clear
31
Please enter today's date below:
Date
Month
Day
Year
Should be Empty: