LIHEAP Form - Community Contacts Inc

847.697.8800 mail@cci-hci.org

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Programs
Housing Continuum Inc
About Us
Contact Us
En Español

LIHEAP Pre-Application

How many people live in your household today? *

APPLICANT INFORMATION

Name *

First

Last

Email *

Phone *

Social Security Number (optional)

Social security numbers, ITINs, or other immigration documents will be required at in person interview.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different than above)

Address Line 1

Address Line 2

City

State

Zip Code

Birthday

Ethnicity

Sex

Age

Are you a veteran?

Yes
No

30 day wages

SSI/SSA

TANF (cash)

Child Support

Pension

AABD

Other

Add additional household members? *

Yes
No

Household Member #2 Information

Name

First

Last

Social Security Number (optional)

We can add a note here about the use of SSN and that they will be collected later if not on this form

Birthday

Ethnicity

Sex

Are you a veteran?

Yes
No

30 day wages

SSI/SSA

TANF (cash)

Child Support

Pension

AABD

Other

Relationship to applicant

Household Member #3 Information

Name

First

Last

Social Security Number (optional)

Sex

Birthday

Ethnicity

Are you a veteran?

Yes
No

30 day wages

SSI/SSA

TANF (cash)

Child Support

Pension

AABD

Other

Relationship to applicant

Household Member #4 Information

Name

First

Last

Social Security Number (optional)

Sex

Birthday

Ethnicity

Are you a veteran?

Yes
No

30 day wages

SSI/SSA

TANF (cash)

Child Support

Pension

AABD

Other

Relationship to applicant

If you have more than 4 household members, we will require that information at the time of appointment. Proof of social security number or other identification will be required at that time.

Are all household members citizens of the United States? *

Yes
No

If not, are they a permanent resident alien?

Yes
No

Is your heat or electric disconnected? *

Yes
No

If yes, which one?

Heat
Electric
Both

Type of home

Do you own or rent? *

Own
Rent

Is your rent subsidized?

Yes
No

What do you pay in rent per month?

Do you pay your own heat bill?

Yes
No

Do you pay your own electric bill?

Yes
No

Do you currently have a past due heating bill?

Yes
No

In addition to your main heating source, do you use any of the following?

Space heaters
Fireplace
Other

Other

What do you use to cool your home? *

Central Air
Wall or window A/C
None

If you checked window or wall A/C, where are the units located?

Sleeping rooms
Common area
Both

How many air conditioner units do you have cooling your home?

How many bedrooms in your home?

How were you referred to CCI and/or LIHEAP? Select all that apply. *

Governor's published announcement
Local news media
Fliers
Social media
Former applicant
Web search
LIHEAP event
Other (please explain)

Thank you for completing the LIHEAP pre-application. You will need to schedule an appointment at one of our offices to complete the application process. Please select from the following options: *

I want to schedule online (after submitting, you will be automatically directed to the online scheduling tool.)
I will call the office to schedule an appointment (847-697-4400)

Community Contacts, Inc. Housing Continuum, Inc.
100 S. Hawthorne,
Elgin, IL 60123
847.697.8800

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