CSBG Application Form

Zero Income Affidavit

This is only to be completed if you (or any adult) has no income (wages, pension, social security, retirement, unemployment, child support, TANF, etc) for the past 90 days.

I, head of household, attest to the fact that my household has received no income for the period covering

Start Date of No Income:

End Date of No Income:

I met my financial obligations during this period with:

$ amount or items:

Name of Source:

Source Phone Number:

Source Address:

Second source:

$ amount or items:

Name of Source:

Source Phone Number:

Source Address:

Last Place of employment or public assistance source (If known):

Name:

Address:

Phone Number:

Date Of Termination:

I understand that to perjure myself in order to obtain assistance is a fraudulent offence for which I can be prosecuted or denied assistance

SIGNATURE:

DATE:

Print Name:

Social Security Number:

Street Address:

City:

State:

Zip:

Child Support Enforcement Referral

This is only required if there are children in the home. If there are, complete the top half if you would like info on how to get child support OR complete the bottom half if not.

I, acknowledge receiving this referral to Child Support Enforcement, which might enable me to activate child support payments on behalf of my child/children. I have also received the following information:

Non-Assistance Program Fact Sheet
Application for Child Support Enforcement Services (Title IV-D)
Illinois Child Support Enforcement locations & telephone numbers

I understand that PCCEO may contact me or Child Support Enforcement to follow up on the status of this referral. I give permission for any PCCEO employee to receive information regarding this referral.

SIGNATURE:

DATE:

Only complete the following part of the form if you do not wish to receive information about activating child support payments.

I, have been offered information that might enable me to activate child support payments on behalf of my child/children. At this time, I do not wish to pursue this option.

SIGNATURE:

DATE:

Universal Signature For Community Services Applications

I, (Head of Household) certify that the information I have provided is an accurate and complete disclosure of the requested information. I also certify that every household member in the application is a resident of Illinois. I authorize this agency to verify the information and contact my landlord, employer, and/or other sources for verification or additional information and to exchange information contained in or otherwise used regarding my application and participating in CSBG/LIHEAP/IHWAP.

Initial forms that were completed for this application:

Select which forms you have completed above:

Intake Form
Statement of Situation Form
Zero Income Affidavit
Child Support Enforcement Referral Form

I understand that to perjure myself in order to obtain assistance is a fraudulent offense for which I can be prosecuted and denied for assistance.

Printed Name:

DATE:

SIGNATURE:

Acknowledgement of Expectations

I, head of household, attest to the fact that I have received emergency lodging assistance. I understand that I am expected to follow the rules of the hotel including, but not limited to:

No smoking in non-smoking rooms
No use of illicit drugs
Only individuals for whom a reservation has been made are permitted to stay in the rooms
Follow courtesy rules including no loud music and no fighting on the premises
Keep room(s) clean

I understand that I will be held financially responsible for any and all incidental charges placed by the hotel for damages the occur during my stay

SIGNATURE:

DATE:

Printed Name:

Phone Number:

Witnessed By:

Letter of Understanding Terms of Emergency Services

I, head of household,

attest to the fact that I have received the following assistance (check all that apply):

Choose services you are applying for:

Rental Assistance
Prescription
Lodging Assistance
Food Voucher Assistance

I understand that my household may only receive this type of service from PCCEO once per calendar year. PCCEO may refer my household to other programs that may provide similar services if needed.

SIGNATURE:

DATE:

Printed Name:

Phone Number:

Witnessed By:

CSBG Application Form

Please choose an application to fill out.

Intake Form

Spouse and Dependent Information: (Optional)

Statement of Situation

Zero Income Affidavit

This is only to be completed if you (or any adult) has no income (wages, pension, social security, retirement, unemployment, child support, TANF, etc) for the past 90 days.

Child Support Enforcement Referral

This is only required if there are children in the home. If there are, complete the top half if you would like info on how to get child support OR complete the bottom half if not.

Only complete the following part of the form if you do not wish to receive information about activating child support payments.

Universal Signature For Community Services Applications

Acknowledgement of Expectations

Letter of Understanding Terms of Emergency Services

Links

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