Community Contacts Inc. Online LIHEAP Application Prescreening

The following is a screening to see if you qualify to complete our online application. Please fill out all fields of required information.

What county do you live in? *

Kane (IL)
DeKalb (IL)
Other
I do not live in Illinois

STOP!

You are attempting to submit a LIHEAP application to an agency that does not serve your county– this application is for KANE and DEKALB Illinois county residents only. Please contact your local administering agency.

What county do you live in? *

You indicated that you live in Cook county. Please contact CEDA.

(800) 571-2332

You indicated that you live in Dupage county. Please contact Dupage County Department of Community Services.
(630) 407-6500

You indicated that you live in Will county. Please contact Will County Center for Community Concerns.

(815) 722-0722

You indicated that you live in Carroll, LaSalle, Lee, Marshall, Ogle, Putnam, Stark or Whiteside county. Please contact the Tri-County Opportunities Council.

(800) 323-5434

You indicated that you live in Kendall or Grundy county. Please contact Kendall-Grundy Community Action (Kendall County Health Department).

Kendall: (630) 553-9100

Grundy: (815) 941-3232

You indicated that you live in Boone or Winnebago county. Please contact the City of Rockford Human Services Department.

(844) 710-6919

You indicated that you live in McHenry county. Please contact the McHenry County Housing Authority.

(815) 338-7752

You indicated that you live in Tazewell, Woodford, McLean, or Livingston county. Please contact Tazwood Community Services, Inc.

(309) 266-9941

You indicated that you do not live in Kane or Dekalb county Illinois. We cannot assist you. Your application will be automatically denied. Please contact your local administering agency and apply for LIHEAP through their services.

This is an application for energy assistance LIHEAP– by submitting this form, you agree that all information you have provided is true and correct.

Please fill out all fields of required information.

How many people live in your household?

Selected Value: 1

**Including yourself and all minors

Before proceeding with this application, you must be prepared to upload supporting documentation immediately following submission. Without supporting documents, we cannot process an application for you.

Proof of income for all household members 18 and over for the past 30 days

If there is NO income in your household, 2 proofs of zero income for each household member 18 and over.

Most recent bills for all energy utilities (EX: ComEd, Nicor, Propane, Fuel Oil).

Social security cards for all household members.

(If you do not have a social or you are undocumented, please provide your ITIN).

Please type "I Understand" to acknowledge the above statement. *

Head of Household (you) *

First

Last

Are you legally disabled? *

Have you received any type of income in the last 30 days? *

Employment/Wages
SSA
SSI
TANF (Cash)
Unemployment
Pension
AABD
Child support
Other
No Income

How often is this income received? *

Monthly
Every week
Every other week
Irregular intervals

When was the last time you worked? Additionally, when was the last time you received any type of income? *

(Cash gifts from anyone with no expectation of repayment is considered income)

Household member's SSN *

Sex *

Ethnicity/Race *

Birthday *

Age *

Are you a veteran? *

Household member 2 *

First

Last

Is this household member legally disabled OR receiving any type of Social Security/Long term disability income? *

Does this household member receive any type of income? *

Employment/Wages
SSA
SSI
TANF (Cash)
Unemployment
Pension
AABD
Child support
Other
No Income

How often is this income received? *

Monthly
Every week
Every other week
Irregular intervals

When was the last time this household member worked? Additionally, when was the last time they received any type of income? *

(Cash gifts from anyone with no expectation of repayment is considered income)

Household member's SSN *

Sex *

Ethnicity/Race *

Birthday *

Age *

Is this household member a veteran? *

Household member 3 *

First

Last

Is this household member legally disabled OR receiving any type of Social Security/Long term disability income? *

3Does this household member receive any type of income? *

Employment/Wages
SSA
SSI
TANF (Cash)
Unemployment
Pension
AABD
Child support
Other
No Income

How often is this income received? *

Monthly
Every week
Every other week
Irregular intervals

When was the last time this household member worked? Additionally, when was the last time they received any type of income? *

(Cash gifts from anyone with no expectation of repayment is considered income)

Household member's SSN *

Sex *

Ethnicity/Race *

Birthday *

Age *

Is this household member a veteran? *

Household member 4 *

First

Last

Is this household member legally disabled OR receiving any type of Social Security/Long term disability income? *

Does this household member receive any type of income? *

Employment/Wages
SSA
SSI
TANF (Cash)
Unemployment
Pension
AABD
Child support
Other
No Income

How often is this income received? *

Monthly
Every week
Every other week
Irregular intervals

When was the last time this household member worked? Additionally, when was the last time they received any type of income? *

(Cash gifts from anyone with no expectation of repayment is considered income)

Household member's SSN *

Sex *

Ethnicity/Race *

Birthday *

Age *

Is this household member a veteran? *

Household member 5 *

First

Last

Is this household member legally disabled OR receiving any type of Social Security/Long term disability income? *

Does this household member receive any type of income? *

Employment/Wages
SSA
SSI
TANF (Cash)
Unemployment
Pension
AABD
Child support
Other
No Income

How often is this income received? *

Monthly
Every week
Every other week
Irregular intervals

When was the last time this household member worked? Additionally, when was the last time they received any type of income? *

(Cash gifts from anyone with no expectation of repayment is considered income)

Household member's SSN *

Sex *

Ethnicity/Race *

Birthday *

Age *

Is this household member a veteran? *

Household member 6 *

First

Last

Is this household member legally disabled OR receiving any type of Social Security/Long term disability income? *

Does this household member receive any type of income? *

Employment/Wages
SSA
SSI
TANF (Cash)
Unemployment
Pension
AABD
Child support
Other
No Income

How often is this income received? *

Monthly
Every week
Every other week
Irregular intervals

When was the last time this household member worked? Additionally, when was the last time they received any type of income? *

(Cash gifts from anyone with no expectation of repayment is considered income)

Household member's SSN *

Sex *

Ethnicity/Race *

Birthday *

Age *

Is this household member a veteran? *

Household member 7 *

First

Last

Is this household member legally disabled OR receiving any type of Social Security/Long term disability income? *

Does this household member receive any type of income? *

Employment/Wages
SSA
SSI
TANF (Cash)
Unemployment
Pension
AABD
Child support
Other
No Income

How often is this income received? *

Monthly
Every week
Every other week
Irregular intervals

When was the last time this household member worked? Additionally, when was the last time they received any type of income? *

(Cash gifts from anyone with no expectation of repayment is considered income)

Household member's SSN *

Sex *

Ethnicity/Race *

Birthday *

Age *

Is this household member a veteran? *

Household member 8 *

First

Last

Is this household member legally disabled OR receiving any type of Social Security/Long term disability income? *

Does this household member receive any type of income? *

Employment/Wages
SSA
SSI
TANF (Cash)
Unemployment
Pension
AABD
Child support
Other
No Income

How often is this income received? *

Monthly
Every week
Every other week
Irregular intervals

When was the last time this household member worked? Additionally, when was the last time they received any type of income? *

(Cash gifts from anyone with no expectation of repayment is considered income)

Household member's SSN *

Sex *

Ethnicity/Race *

Birthday *

Age *

Is this household member a veteran? *

Household member 9 *

First

Last

Is this household member legally disabled OR receiving any type of Social Security/Long term disability income? *

Does this household member receive any type of income? *

Employment/Wages
SSA
SSI
TANF (Cash)
Unemployment
Pension
AABD
Child support
Other
No Income

How often is this income received? *

Monthly
Every week
Every other week
Irregular intervals

When was the last time this household member worked? Additionally, when was the last time they received any type of income? *

(Cash gifts from anyone with no expectation of repayment is considered income)

Household member's SSN *

Sex *

Ethnicity/Race *

Birthday *

Age *

Is this household member a veteran? *

Household member 10 *

First

Last

Is this household member legally disabled OR receiving any type of Social Security/Long term disability income? *

10Does this household member receive any type of income? *

Employment/Wages
SSA
SSI
TANF (Cash)
Unemployment
Pension
AABD
Child support
Other
No Income

How often is this income received? *

Monthly
Every week
Every other week
Irregular intervals

When was the last time this household member worked? Additionally, when was the last time they received any type of income? *

(Cash gifts from anyone with no expectation of repayment is considered income)

Household member's SSN *

Sex *

Ethnicity/Race *

Birthday *

Age *

Is this household member a veteran? *

Are all household members citizens of the United States? *

Who in the household is not a citizen? Are they a permanent resident? *

Is your heat or electric disconnected? (not disconnection notice) *

Which utility are you currently disconnected from? *

STOP!

Stop Sign PNG, Stop Sign Transparent Background - FreeIconsPNG

You indicated that you are physically disconnected from one or more of your utilities. Please immediatley contact the office at (847) 697-4400 upon completing your application and notify us of your emergency so we can process your application as a reconnection assistance application.

Primary Phone number *

Example: xxxxxxxxxx

Email *

Do you own or rent your home? *

Do you pay rent? *

If you are on subsidized housing (section 8), select “Yes” and enter the amount of rent you are responsible for.

Please select the energy utility bill(s) you pay. *

Natural Gas
Electric
Fuel Oil
Propane
Other

What other utility bills do you pay? *

What do you use to cool your home? *

Secondary Phone number

Example: xxxxxxxxxx

Secondary email

Please select your housing type.

How much is your rent?

Are you past due on any of these bills? *

Where are the window/wall units located in your home? *

How many air conditioner units are in your home? *

How many bedrooms are in your home? *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you have a mailing address that is DIFFERENT than above?

Mailing address *

Address Line 1

Address Line 2

City

State

Zip Code

Are you interested in financial literacy tips to help you manage your household income? *

Are you interested in energy conservation tips for your home or apartment so you can save money on your utility bill? *

Are you interested in information about SSI (Supplemental Security Income)? *

If you already receive SSI, you may mark “No”.

Do you have a safe place to go if you are disconnected from your heat source? *

If you are a homeowner and your residence has not been weatherized in the last 15 years, are you interested in information about the weatherization program? *

Are you interested in information about the Illinois Department of Aging? *

If a household member is a Veteran of the United States Armed Forces, would you like information on Veteran's benefits? *

Are you interested in information about Unemployment Insurance Benefits and job searches? *

If everyone in your household does not have health insurance, are you interested in information about Medicaid? *

Are you interested in local food pantries or nutrition programs such as: Women, Infants, and Children (WIC) or SNAP (Food Stamps), and/or Meals on Wheels or group meal sites for the elderly? *

Does anyone in your household receive SNAP? *

Are you interested in help with childcare while you work, and/or in pre-school for your child or children? *

How were you referred to LIHEAP? *

Are you being assisted in filing this form by a professional? *

Who is assisting you with your application, and what agency are they from? *

Updating preview…

This is a preview of your submission. It has not been submitted yet!
Please take a moment to verify your information. You may go back to make changes if necessary.

Community Contacts Inc. Online LIHEAP Application Prescreening

STOP!

You indicated that you live in Cook county. Please contact CEDA.

(800) 571-2332

You indicated that you live in Dupage county. Please contact Dupage County Department of Community Services. (630) 407-6500

You indicated that you live in Will county. Please contact Will County Center for Community Concerns.

(815) 722-0722

You indicated that you live in Carroll, LaSalle, Lee, Marshall, Ogle, Putnam, Stark or Whiteside county. Please contact the Tri-County Opportunities Council.

(800) 323-5434

You indicated that you live in Kendall or Grundy county. Please contact Kendall-Grundy Community Action (Kendall County Health Department).

Kendall: (630) 553-9100

Grundy: (815) 941-3232

You indicated that you live in Boone or Winnebago county. Please contact the City of Rockford Human Services Department.

(844) 710-6919

You indicated that you live in McHenry county. Please contact the McHenry County Housing Authority.

(815) 338-7752

You indicated that you live in Tazewell, Woodford, McLean, or Livingston county. Please contact Tazwood Community Services, Inc.

(309) 266-9941

You indicated that you do not live in Kane or Dekalb county Illinois. We cannot assist you. Your application will be automatically denied. Please contact your local administering agency and apply for LIHEAP through their services.

This is an application for energy assistance LIHEAP– by submitting this form, you agree that all information you have provided is true and correct.

Before proceeding with this application, you must be prepared to upload supporting documentation immediately following submission. Without supporting documents, we cannot process an application for you.

STOP!

You indicated that you live in Dupage county. Please contact Dupage County Department of Community Services.
(630) 407-6500