Tenant's Assistance Program (TAP) Intake Form
LCHA is HUD Approved Housing Counseling Agency # 80113
Are you applying for assistance with DELINQUENT RENT or SECURITY DEPOSIT? (please note, this program only assists with delinquent rent and/or security deposit)
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Yes
No
Is your rental unit located in LAKE COUNTY, ILLINOIS?
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Yes
No
Do you owe LESS THAN 3 months' rent to your current landlord? (please note, TAP can assist with a MAXIMUM of three months' delinquent rent)
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Yes
No
Are you able to cover the financial costs of housing, utilities, and transportation AFTER this subsidy has ended?
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Yes
NO
Are you able to document the temporary crisis or financial emergency that caused you to need this assistance?
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Yes
NO
I would like to speak to program staff about this question.
LCHA is not permitted by our funder to provide households more than 3 months of delinquent rent or 2 months worth of security deposit.
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I understand that the maximum assistance I will receive is 3 months in deliquent rent or 2 months worth of security deposit. If I owe more than this and cannot verify that I have the funds to pay the difference out of pocket, I will be disqualified from TAP assistance.
I acknowledge this but would like to speak to program staff about this question.
This program requires that Landlords or Property Managers accept the funds directly from LCHA. Applicants whose landlords do not accept these funds will be disqualified. No assistance will be issued directly to applicants.
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I understand that this program will require landlord or property manager participation and without this participation, my application will be disqualified and closed.
I acknowledge this but would like to speak to program staff about this question.
Applicants who have received funding from this specific program within the past 2 years are disqualified per guidelines.
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I understand that LCHA program staff will verify if I have received assistance from this specific program in the past 2 years, and my application will be closed if my household has received assistance within this timeframe.
I acknowledge this but would like to speak to program staff about this question.
This program requires that applicants have personally inspected the unit prior to application and will attest that the property is move-in ready and has no obvious health or housing violations. Applicant understands that the Tenant's Assistance Program does not inspect rental units. Any issues that arise must be addressed with the landlord and/or through legal channels.
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I attest that I have inspected the unit where I will be moving. I understand that any housing or health violation should be addressed with the landlord and/or legal channels. I understand that the Security Deposit Assistance program does not inspect the unit prior to the applicant moving in.
This program has limited funds. Assistance is on a first come, first serve basis and funds are subject to availability.
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I understand that funding is subject to availability and that applications are reviewed on a first-come, first-served basis and that I will be notified by program staff if funding has run out.
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Head of Household Information
Name for Head of Household
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First Name
Last Name
How many persons are in your household?
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Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Head of Household Date of Birth
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Month
-
Day
Year
Date
Head of Household Social Security Number
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Head of Household Status
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Single Male, NO children
Single Female, NO children
Couple No Child
Couple with Child/Children
Single Male with Child/Children
Single Female with Child/Children
Head of Household Highest Level of Education
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Above Masters Degree
Masters Degree
Bachelor's Degree
Junior College
HS Diploma or Equivalent
Below HS Diploma
Elementary
Other
Head of Household Race
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American Indian / Alaskan Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander
White
American Indian / Alaskan Native & White
Asian & White
Black / African American & White
American Indian / Alaskan Native & Black / African American
Other
Head of Household Ethnicity
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Hispanic or Latino
Non-Hispanic and Non-Latino
Head of Household Veteran Status
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Active Military
Veteran
NOT a Veteran OR Active Military
Head of Household Disability Status
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Disabled
Not Disabled
Head of Household Primary Language
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Current Address (NOT the address of the future rental)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Additional Persons in Household
Person #2
Name of Person #2
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First Name
Last Name
Is Person #2 Disabled?
Yes
NO
Person #2 Gender
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Female
Male
Person #2 Date of Birth
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Month
-
Day
Year
Date
Person #2 Social Security Number
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Person #2 Race
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American Indian / Alaskan Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander
White
American Indian / Alaskan Native & White
Asian & White
Black / African American & White
American Indian / Alaskan Native & Black / African American
Other
Person #2 Ethnicity
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Hispanic or Latino
Non-Hispanic and Non-Latino
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Additional Persons in Household
Person #3
Name of Person #3
First Name
Last Name
Is Person #3 Disabled?
Yes
No
Person #3 Gender
Female
Male
Person #3 Date of Birth
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Month
-
Day
Year
Date
Person #3 Social Security Number
Person #3 Race
American Indian / Alaskan Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander
White
American Indian / Alaskan Native & White
Asian & White
Black / African American & White
American Indian / Alaskan Native & Black / African American
Other
Person #3 Ethnicity
Hispanic or Latino
Non-Hispanic and Non-Latino
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Additional Persons in Household
Person #4
Name of Person #4
First Name
Last Name
Is Person #4 Disabled?
Yes
No
Person #4 Gender
Female
Male
Person #4 Date of Birth
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Month
-
Day
Year
Date
Person #4 Social Security Number
Person #4 Race
American Indian / Alaskan Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander
White
American Indian / Alaskan Native & White
Asian & White
Black / African American & White
American Indian / Alaskan Native & Black / African American
Other
Person #4 Ethnicity
Hispanic or Latino
Non-Hispanic and Non-Latino
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Additional Persons in Household
Person #5
Name of Person #5
First Name
Last Name
Is Person #5 Disabled?
Yes
No
Person #5 Gender
Female
Male
Person #5 Date of Birth
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Month
-
Day
Year
Date
Person #5 Social Security Number
Person #5 Race
American Indian / Alaskan Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander
White
American Indian / Alaskan Native & White
Asian & White
Black / African American & White
American Indian / Alaskan Native & Black / African American
Other
Person #5 Ethnicity
Hispanic or Latino
Non-Hispanic and Non-Latino
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Household Assistance Program Participation Information
Does anyone in the household receive ... (choose all that apply)
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Medicare
Medicaid
Employer Provided Insurance
Private Insurance
CHIP
SNAP
WIC
LIHEAP Utility Assistance
Illinois Child Care Assistance Program (CCAP)
RTA Free / Reduced Fare Programs
FCC Lifeline for Internet OR Phone
Affordable Connectivity Program (ACP) for reduced internet costs
Housing Voucher with Lake County Housing Authority
Housing Voucher with Waukegan Housing Authority
Housing Voucher with North Chicago Housing Authority
None of the Above
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Income and Expenses
Please Record All Sources of Income for the ENTIRE household:
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Amount Per MONTH
Wages from Employment
Social Security or Disability
Unemployment
Child Support
Regular Cash Gifts
TANF
Housing Choice Voucher
VA Benefits (active duty)
VA Benefits (retired)
Other
Please Record Expenses for the ENTIRE household:
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Amount Per MONTH
Rent
Renters Insurance
Car Payment
Auto Insurance
Gas
Bus or Train Fare
Uber / Lyft
Cell Phone
Internet
Natural Gas
Electricity
Garbage / Water / Sewer
Groceries / Household Goods
Childcare or Eldercare
Education / Tuition
Prescription Drugs
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I am applying for (CHOOSE ONLY ONE)
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Delinquent Rent ONLY.
Security Deposit ONLY.
BOTH Delinquent Rent AND Security Deposit.
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To apply for Delinquent Rent:
I attest that without assistance with delinquent rent, my housing with be subject to eviction and therefore will be at risk of homelessness.
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Yes. Without assistance, my household will be at risk for homelessness.
Current Landlord Name
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First Name
Last Name
Current Landlord's OR Property Manager’s Email
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example@example.com
Current Landlord's OR Property Manager’s Phone Number
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Please enter a valid phone number.
Current Amount of Monthly Rent per Lease
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Amount of Tenant's Portion (for Voucher Holders)
Amount of Rent Currently Owed
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To Apply for Security Deposit
I attest that without Security Deposit Assistance, I will not be able to secure housing, and will therefore be at risk for homelessness.
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Yes. Without assistance, my household will be at risk for homelessness.
FUTURE Address where security deposit is needed:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FUTURE Landlord's Name
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First Name
Last Name
FUTURE Landlord's OR Property Mananger's Email
*
example@example.com
FUTURE Landlord's OR Property Mananger's Phone Number
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Please enter a valid phone number.
FUTURE Amount of Monthly Rent per Lease
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Amount of Tenant's Portion (for Voucher Holders)
Amount of Security Deposit
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What date will you be moving in?
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Month
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Day
Year
Date
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I hereby verify that I have received Fair Housing information/material regarding rights and remedies available under federal, state, and local fair housing and civil rights laws. Counseling services and other forms of assistance that may be offered by Lake County Housing Authority, its affiliates or directors, officers, employees, agents or partners may also be offered by other providers. You are under no obligation to utilize services from Lake County Housing Authority, regardless of the recommendations made by counselors. Housing Counseling clients are not obligated to use any program or service offered by LCHA, their affiliates or partners. The Office of Housing Counseling will provide information on alternative programs and services. Clients should consider a variety of options and select the resources that best addresses their needs. Signature
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Please read the following Disclosure to Client and Privacy Policy
I have read and received a copy of the disclosures (pages 1 & 2)
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LCHA's Privacy Policy
Please read LCHA's Privacy Policy regarding your nonpublic personal information:
Regarding your nonpublic personal information:
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OPT-OUT: I request that LCHA make no disclosures of my nonpublic personal information to third parties other than project partners and those permitted by law. By choosing this option, I understand that LCHA will NOT be able to answer any questions from my creditors. I understand that I may change my decision any time by contacting LCHA.
OPT IN / RELEASE: I hereby authorize LCHA to release nonpublic personal information it obtains about me to my creditors and any third parties necessary to provide me with the services I requested. I acknowledge that I have read and understand the above privacy practices and disclosures.
Privacy Policy & Ability to OptOut: I have read and received a copy of LCHA's HSCP Authorization and Disclosure as well as the Privacy Policy, including my option to opt out of the above terms and the release/disclosure ofany nonpublic, personal information.
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Credit Report Authorization and Privacy Disclosure Form
I hereby authorize and instruct Lake County Housing Authority (hereinafter “LCHA”) to obtain and review my credit report/s. My credit report/s will be obtained from credit reporting agencies chosen by LCHA. I understand and agree that LCHA intends to use my credit reports only for the purpose of evaluating my financial circumstances, to engage in counseling activities and/or to establish my readiness to purchase a home.
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I Agree
My signature below authorizes the release of personal and financial information that I have supplied to LCHA in connection with such evaluation. Authorization is further granted to LCHA to use a copy of this form to obtain any information the LCHA deems necessary to complete my financial evaluation or create my personalized action plan.
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I Agree
I understand that any debt management or spending plans suggested by an LCHA counselor are voluntary programs which serve to assist in the repayment of debts. These are not formal or binding agreements with debt holders, lenders, or creditors. LCHA maintains no formal agreement or affiliation with any debt holder, lender, or creditor.
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I Agree
I understand that LCHA is not a lender and does not issue loans or credit.
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I Agree
I understand that LCHA will be executing a "soft pull". A soft pull allows authorized parties to review your credit but these inquiries but do not allow associated lending decisions. A soft pull will not affect my credit score.
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I Agree
I understand that I may revoke my authorization to these provisions at any time by contacting LCHA in writing.
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I Agree
Signature
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Today's Date
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Month
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Day
Year
Date
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Please read the following Authorization to Share Information Using ServicePoint
Is the person signing a minor?
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Yes
No
Name of Person Signing
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First Name
Last Name
This Authorization expires on (please choose a date one or more years from today)
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Month
-
Day
Year
Date
I have read and understand the above material and I hereby consent that Lake County and the Participating Agencies use, disclose, enter, transmit, and share the Protected Health Information for me or my child(ren)/ward(s)/dependent(s) identified below using ServicePoint® and, if I am between the ages of 13-17, to share Protected Health Information with my parent or guardian.
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Document Uploads
ALL APPLICANTS ARE REQUIRED TO SUBMIT A LEASE, PROOF OF INCOME, AND PROOF OF HARDSHIP. YOUR APPLICATION WILL NOT BE CONSIDERED COMPLETE WITHOUT THESE DOCUMENTS. YOU CAN ATTACH THEM HERE OR EMAIL THESE TO YOUR TAP CASE MANAGER. OTHER DOCUMENTS MAY BE REQUESTED ON A CASE-BY-CASE BASIS.
Lease for the unit where you are applying for assistance
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Ledger of Rents Owed (for those applying for delinquent rent)
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RFTA for FUTURE Unit (for voucher holders only)
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Income Documentation
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Proof of Crisis or Hardship
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CLICK HERE TO SUBMIT APPLICATION
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