Membership Application Form

To Those in Need From the City of Chi-Raqi /Membership Application (HOCTD)

to qualify as a recipient for benefit's for one of our Public work's Projects- we Need a copy of a Valid Illinois State I.D. or a copy of Valid U.S. I.D. Card and or Voter Registration card or two pieces of Mail with matching Address for Cook County/Suburb/Low/Middle Income Illinois/North-West Indiana Residence within Last six Months And a copy of a Recent Proof of Earnings Statement - which can be obtained from your local Social Security office, or one of the last two years W-2 statements
IF YOU DON'T NEED ASSISTANCE, BUT WANT TO JOIN, YOU MUST SHOW I.D.
(DO NOT UPLOAD IMAGES INTO UPLOAD SLOTS YOU DO NOT WISH TO FILL)
_______________________________________________________________________
Application for Assistance From the Clergy & Congregation of -
House of Christ - Temple Divine - Chicago
-(Chi-Raqi)-
I Am Asking for Assistance from House of Christ - of my own free will
Name

PrefixFirst NameMiddle NameLast Name
AGE RANGE
DATE OF BIRTH

MonthDayYear
GENDER
CHILDREN
SPOUSE
ADDRESS LINE1
ADDRESS LINE2
CITY
STATE
COUNTY
ZIP CODE
CHOOSE ONE
E-mail
PHONE

Area CodePhone Number
IDENTIFICATION
STATE I.D. ISSUED
I.D. EXPIRES

MonthDayYear
Date
I.D.#
UPLOAD VALID I.D.

Upload a File

Cancelof
or USE Mobile Upload
Mobile
FINANCIAL ASSISTANCE QUALIFICATIONS
if the answer is "NO" Skip to: ARE YOU EMPLOYED*, you are "NOT" required to provide "Proof of Residence" or "Earning Statements".
EARNINGS STATEMENT

Upload a File
REQUIRED TO VERIFY ELIGIBILITY FOR RELIGIOUS ASSISTANCE PROGRAMS Cancelof
UPLOAD PROOF OF RESIDENCE

Upload a File
REQUIRED TO VERIFY IDENTITY FOR RELIGIOUS FINACIAL ASSISTANCE Cancelof
ARE YOU EMPLOYED
PLACE OF EMPLOYMENT
ARE YOU CURRENTLY ENROLLED IN SCHOOL?
SCHOOL (MAJOR)
Do you currently recieve S.N.A.P. / T.A.N.F. or other Public Assistance?
ARE YOU DISABLED
IF DISABILITY STATUS IS PENDING - PLEASE GIVE A BRIEF DESCRIPTION
Are you Currently Enrolled in the A.C.A. (Affordable Care Act) - (Obama-Care) ? or Chicago's Cook County Care?
Are you, U.S. Armed Forces ?
ARE YOU CURRENTLY
Would you Like to Become a Member of H.O.C.T.D.
I Verify tht I am a Resident of Chi-Raqi (Chicagoland)
I AM A "CHI-RAQI NATIONAL"
I Have Answered all the Above questions to the Best of My Ability - In Full truth to the Best of My Knowledge. I Understand that Knowingly Submitting falsified Documents (Fake I.D./Fake W-2/Stolen Mail/ Stolen Voter Registration) or falsifieng Disability status or Impersonating an Officer for Financial Gain. Are all Illegal Acts (Fraud/ Identity Theft at a Federal Level Which can Lead to a Class x Felony if Convicted). which we reserve the right to pursue charges and Have you Removed from the Orginization for a period of one (1) Year (No Less than 365 Days)to Be Reviewed Annually.
COMMENT
Enter the message as it's shown
Should be Empty:

To Those in Need From the City of Chi-Raqi /Membership Application (HOCTD)