INSTRUCTIONS ON FILLING OUT THE PRE-APPLICATION PACKET

* APPLICATION SUBMISSION DOES NOT GUARANTEE APPROVAL FOR BENEFITS.

1. LIHEAP Applicants (Utility Assistance) must complete pages 3-9, applicants looking for other assistance must fill out all pages completely.
2. Check the box on the Universal Signature Page for the assistance you are applying for.
3. All information on the Contact Information must be filled out and accurate.
4. Be sure to fill in Utility Vendor name, Account Number and Name of person on bill.
5. Complete All Members of Household with full social security number, full name, date of birth, gender, disabled, ethnic group, education and the amount of income received.
6. Anyone 18 years or older with no income needs to be listed on the Zero Income Affidavit and completely filled out.
7. Budget sheet needs to be filled out to the best of your ability.
8. Resource Referral page needs to be completely filled out.

How to turn in all required documents with pre-application packet:

1. Mailing to NICAA, 27 S. State Ave, Suite 102, Freeport, IL 61032
2. Fax them to: 815-232-3143
3. Or email to: [email protected]

REQUIRED DOCUMENTATION CHECKLIST

The following items are needed to begin the application process within the Community Services Department of NICAA. Please submit ALL the items with the packet.

The packet (filled out completely) with the requested information must be returned no later than 15 days from the date it is signed. If it is returned after the 15 days, the agency reserves the right to request additional information. The agency reserves the right to request proof of income for the past 30 days.

UNIVERSAL SIGNATURE PAGE

IMPORTANT NOTICE: This state of Illinois grantee agency is requesting disclosure information that is necessary to accomplish a complete application for:

APPLICANT STATEMENT

I 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 utility/fuel supplier, landlord, employer and/or other sources for verification or additional information and to exchange information contained in or otherwise used regarding my application and participation in CSBG/LIHEAP/IHWAP.

For LIHEAP and IHWAP I also authorize the Department of Commerce & Economic Opportunity and my utility/fuel supplier to share my usage and bill information during the twenty-four (24) month period prior to and twelve (12) month period after the date of my application submittal and/or completion of LIHEAP and IHWAP services for the purpose of program evaluation and analysis.

I have received information outlining my appeal rights. I understand that filling out this application does not guarantee that my household will receive assistance. I understand I will be provided a copy of this application for my future reference.

If you have additional household members to add, please email their information to us. Also, include your information so that we can put them in your file. Our email is: [email protected]

PERSONAL AND FAMILY WITH ZERO-INCOME AFFIDAVIT

This form must be completed if the applicant or a family member in their household is 18 years or older and has reported no income for the last 30 days.

I certify that the information above is true and correct. I understand I may be required to provide proof of any information given. I understand that providing false information will result in the denial of my application.