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Community Action Program Financial Assistance Application
Family Service Agency's Community Action Program will assist eligible households in eliminating barriers to employment among SNAP, TANF, and Medicaid recipients in DeKalb County, Illinois. When funding is available, and households meet the required eligibility criteria, households may be provided assistance to address barriers to employment. Financial assistance may be applied towards a number of barriers, including but not limited to vehicle maintenance, work supplies, union dues, clothing, rental payments, and childcare.
Waitlist
We truly understand how difficult this time may be for you and want to assure you that we are here to help as soon as we can. While we currently have a seven-week waitlist, we encourage you to contact 211 in the meantime to connect with other resources that may provide support during this time.
Can you provide proof of residency within DeKalb County, Illinois? (government-issued ID, lease, mortgage, utility bill, bank statement, benefits letter, shelter placement, etc.)
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Yes
No (you are ineligible for this assistance program)
Which of the following benefits are you currently receiving? (select all that apply)
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SNAP
TANF
TANF Child Only
Medicaid
None of the Above
Select the option that best describes your situation....
*
I am currently employed
I am currently employed, but I'm seeking new employment
I am currently unemployed, and I'm seeking employment
I am currently unemployed, and I'm NOT seeking employment
I am unable to work
What resource(s) are you utilizing to locate employment? (select all that apply)
*
Job Search Site (Indeed, LinkedIn, Job Monster, etc.)
Illinois Work Net (workNet Batavia)
Passion Pursuit (Coach Danita)
Community Action Program
I am not seeking employment.
Other
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Financial Assistance
What type of assistance are you seeking?
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Auto Repairs
Childcare Payments
Clothing for Work
Education Supplies
Hygiene Products
Medical (physical exam, drug test, etc. required for work)
Telephone (phone, minutes, etc.)
Testing Fees
Tools or Equipment
Transportation (bus pass, Uber, Lyft, gas card)
Tuition (CNA classes, etc.)
Work Uniforms
Union Dues
Past due Rent
Other
Please explain how assistance will help you maintain or gain employment
*
Provide a brief explanation of why you're seeking services.
*
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Applicant Information
FSA does not discriminate on the basis of race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, marital status, veteran status, or any other characteristic protected by law.
Applicant Name
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First Name
Last Name
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
What is your military status?
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Active Duty
Veteran
No Affiliation
Other
Additional Information Required
What is your housing situation?
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Rent
Mortgage
Own (paid off)
Homeless (on street, in vehicle, etc.)
Homeless (couch surfing)
Homeless (in shelter)
Other
Do you have renter's insurance?
*
Yes
No
I don't rent
Unsure
What is your estimated monthly household income?
*
Who is working in your household?
*
Who is the employer?
*
Are you currently receiving case management services from any organization?
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Yes, Association for Individual Development
Yes, Ben Gordon Center
Yes, Hope Haven
Yes, Safe Passage
Yes, Family Service Agency / Community Action Program
Unsure
No, I am not receiving case management services from any organization.
Have you received services from Family Service Agency in the past or currently? (select all that apply)
*
Yes, Children's Advocacy Center
Yes, School-Based & Youth Programming
Yes, Center for Counseling
Yes, Senior Services
Yes, Community Action Program
Unsure
No, I have not received services from Family Service Agency.
How did you hear about FSA's Community Action Program?
*
Social Media
Google / Search Engine
Friend, Neighbor, or Family Member
Employer
DeKalb Township
City of DeKalb
Hope Haven
Safe Passage
Other
Safety Considerations, is there anything we should know to help keep you safe? (examples: don't call after 3:00pm, prefer to communicate via email, etc.)
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Submit Application
Once your application is submitted, a Family Support Specialist will be in touch to schedule an appointment. In the meantime, please collect the following documentation: IDs for all adults in the home, 30 days of income for all individuals in the home, recent benefits letter, and proof of employment (if applicable).
I certify that the information in this application is accurate. I understand that Family Service Agency will notify the Illinois Department of Human Services if I am found to be submitting false information during my application process, which may result in me losing my benefits or criminal investigation.
Submit
Submit
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