Have you ever been convicted of a felony? Yes No  Pregnant Now? Yes No Client Does Not Know Client Refused    Is juvenile a parent (under age 18)? Yes No  HOMELESSNESS PREVENTION/ RAPID RE-HOUSING - Eligibility Checklist Select the situation(s) that caused you to need assistance. All hardships must be documented and verified.  Loss of income/job  Natural Disaster/Fire  Car Repair  Funeral Expenses  Medical Expenses  Displacement by Gov.  Condemnation  Foreclosure    Release from institution Loss of hours at work Other Applicable __________________________________  Homeless Describe Current Crisis/Need for Assistance/Housing Situation: Is the household unable to identify appropriate subsequent housing options; AND do they lack the financial resources and support networks needed to obtain immediate housing or remain in existing housing? Yes No   Is the household unable to relocate with another family member or friends? Yes No   Does the household lack sufficient savings or other assets that can be used to pay rent, arrearages and other housing costs? (Must provide statements for any bank accounts) Yes  No  If No, Total savings/assets: Eligibility Criteria by ESG ESG Rapid READE IDHS Program Type Prevention Re-housing Prevention Prevention Housing Status Imminently at Literally Homeless Imminently at    Risk of becoming in suburban Cook Risk of becoming homeless County 2 weeks or homeless more Current or Last In suburban In suburban Cook In South region In Illinois     Permanent Address Cook County for County within last six of suburban Cook at least 1 month months County no income restriction Income  Below 30% AMI  Income at initial intake - sufficient to Below 30% AMI at cover rent redetermination only Evidence of Hardship Required Required Required   
Have you ever been convicted of a felony?  Yes No Pregnant Now?  Yes No  Client Does Not Know  Client Refused Is juvenile a parent (under age 18)?  Yes No HOMELESSNESS PREVENTION/ RAPID RE-HOUSING - Eligibility Checklist Select the situation(s) that caused you to need assistance. All hardships must be documented and verified.  Loss of income/job  Natural Disaster/Fire  Car Repair  Funeral Expenses  Medical Expenses  Displacement by Gov.  Condemnation  Foreclosure  Release from institution  Loss of hours at work  Other Applicable __________________________________  Homeless Describe Current Crisis/Need for Assistance/Housing Situation: Is the household unable to identify appropriate subsequent housing options; AND do they lack the financial resources and support networks needed to obtain immediate housing or remain in existing housing?  Yes  No Is the household unable to relocate with another family member or friends?  Yes  No Does the household lack sufficient savings or other assets that can be used to pay rent, arrearages and other housing costs? (Must provide statements for any bank accounts)  Yes  No If No, Total savings/assets: Eligibility Criteria by Program Type ESG Prevention ESG Rapid Re-housing READE Prevention IDHS Prevention Housing Status  Imminently at Risk of becoming homeless  Literally Homeless in suburban Cook County 2 weeks or more  Imminently at Risk of becoming homeless Current or Last Permanent Address  In suburban Cook County for at least 1 month  In suburban Cook County within last six months  In South region of suburban Cook County  In Illinois Income  Below 30% AMI no income restriction at initial intake - Below 30% AMI at redetermination only  Income sufficient to cover rent Evidence of Hardship  Required  Required  Required