2023 LIOP Client Registration Form

Please fill out the following form so that we can best serve you during your apartment search!
All information will remain confidential and will only be used by the Oak Park Regional Housing Center advisors or counselors. Upon submission, staff will contact you with apartment listings that match your needs! If you have any questions, please call our office at 708-848-7150.

The Civil Rights Act of 1968, also known as the Fair Housing Act, prohibits discrimination concerning the sale, rental, and financing of housing based on race, religion, national origin, sex, handicap, and family status. A primary goal of the Fair Housing Act is to achieve a housing market in which a person's background does not arbitrarily restrict access. The Fair Housing Act is in place to protect buyers and renters from seller and landlord discrimination. Fair Housing is a core tenet of the Oak Park Regional Housing Center and our programming!

Today's Date

Date

Your Named

First NameLast Name

Your Current CITY of Residence

State or Other Continent/Country

Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

YEARLY Total Combined Household Income (Before Taxes)

ADD THE INCOMES OF EACH ADULT IN THE HOUSEHOLD

30% of the Total Monthly Household Income

30% of Total Monthly Household Income

Anticipated Maximum Rent Budget

This budget should be similar to or below the above 30% figure

Are you a full-time student and receiving rental assistance from loans and/or parental support?

Credit Score (if known)

Please select your current credit rating

When is the absolute earliest date you can move?

Date

When is the absolute latest date you can move?

Date

Total Persons (Including Children) to Occupy Apartment

Bedrooms Needed

Do you require pet friendly listings?

If you said "Yes, allows dogs", please specify the weight of dog.

Any special requirements? (For example: Near the Blue Line, Top Floor, Hardwood, etc.)

This is your chance to let us know what you need in your apartment!

How did you learn about us?

Are you using a Housing Choice Voucher?

If yes, which Housing Authority provided the Voucher?

The information on this intake form will remain confidential. However, it is vital funding/grant information required for reporting in aggregate to HUD and all content on this page is required by HUD. Please complete below:

Are you a female head of household (the member of the family who has been designated by the family as the head for purposes of determining income eligibility and rent)?

Are you (or another household Adult) of Hispanic / Latinx ethnicity?

Are you (or another household Adult) of Arab or Middle Eastern ethnicity?

Racial Identity: Please Indicate the Race(s) of Adults in the Household. Check all that apply.

Rows	You	2nd Adult	3rd Adult
White A person having origins in any of the original people of Europe, the Middle East or North Africa
Black / African American A person having origins in any of the black racial groups in Africa or the Caribbean
Asian A person with origins in any of the peoples of the Far East, Southeast Asia or the Indian subcontinent including for example: Afghanistan, Bangladesh, Cambodia, China, India, Japan, Korea, Laos, Malaysia, Mongolia, Pakistan, Philippine Islands, Thailand and Vietnam
American Indian / Alaskan Native A person having origins in North, Central or South America who maintains a tribal community attachment (not just claim of ancestry)
Native Hawaiian / Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands
American Indian or Alaska Native AND White
Asian AND White
Black / African American AND White
American Indian / Alaska Native AND Black / African American

Your signature below indicates that you accept disclosure of your new address (or nearest cross streets) as terms of agreement for our service.
Draw your signature using your mouse or finger / stylus if you are using a touchscreen device.

Signature

For Office Use Only: The following section is to be filled out by the Housing Center. Please do not answer any of the following questions.

ID #: Advisor: Admin / Public Service

G: Date: Time:

Final Result: Date:

Close-Out Date: Aff Move? Y / N

Listings:

30-Day Follow-Up Email:
Initials & Date
60-Day Follow-Up Call:
  Initials & Date
90-Day Follow-Up Call:
  Initials & Date