For Each Individual Household Member with income, record their individual total income from all sources below Household Member Total Monthly Income Household Member Total Monthly Income Total Monthly Household Income $_________________ Number of Household Members _______ FY2017 Area Median Income (AMI) Household Size 1 2 3 4 5 6 7 8 15% AMI $742 $848 $954 $1,059 $1,144 $1,229 $1,313 $1,398 30% AMI $1,383 $1,583 $1,779 $1,975 $2,133 $2,292 $2,450 $2,608 50% AMI $2,304 $2,633 $2,963 $3,292 $3,558 $3,821 $4,083 $4,346 80% AMI $3,688 $4,217 $4,742 $5,267 $5,692 $6,113 $6,533 $6,954 100% AMI $4,608 $5,267 $5,925 $6,583 $7,117 $7,642 $8,167 $8,692 Total Monthly Household Income As Percentage Of AMI: Below 30% 30%-49% 50%-79% 80%-99% 100% and above      50% and Above Illinois RIN# Optional (Illinois Recipient Identification Number for Non-Cash Benefits and Health Insurance) Non-Cash Benefits Does the household currently receive any Non-Cash Benefits? Yes No Client Does Not Know Client Refused     If No - Do you need assistance in applying for non-cash benefits? Yes No   Please indicate which of the following non-cash benefits have you received over the last 30 days. (You may if all household members receive the benefit) use “All” Start Date Amount (optional) Supplemental Nutrition Assistance Program (Food Stamps) Yes No If Yes, Household Members:  Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Yes No If Yes, Household Members:  TANF child care services Yes No If Yes, Household Members:  TANF transportation services Yes No If Yes, Household Members:  Other TANF-Funded Services Yes No If Yes, Household Members:  Other Source (specify): Yes No If Yes, Household Members: 
For Each Individual Household Member with income, record their individual total income from all sources below Household Member Total Monthly Income Household Member Total Monthly Income Total Monthly Household Income $_________________ Number of Household Members _______ FY2017 Area Median Income (AMI) Household Size 1 2 3 4 5 6 7 8 15% AMI $742 $848 $954 $1,059 $1,144 $1,229 $1,313 $1,398 30% AMI $1,383 $1,583 $1,779 $1,975 $2,133 $2,292 $2,450 $2,608 50% AMI $2,304 $2,633 $2,963 $3,292 $3,558 $3,821 $4,083 $4,346 80% AMI $3,688 $4,217 $4,742 $5,267 $5,692 $6,113 $6,533 $6,954 100% AMI $4,608 $5,267 $5,925 $6,583 $7,117 $7,642 $8,167 $8,692 Total Monthly Household Income As Percentage Of AMI:  Below 30%  30%-49%  50%-79%  80%-99%  100% and above 50% and Above Illinois RIN# Optional (Illinois Recipient Identification Number for Non-Cash Benefits and Health Insurance) Non-Cash Benefits Does the household currently receive any Non-Cash Benefits?  Yes  No  Client Does Not Know  Client Refused If No - Do you need assistance in applying for non-cash benefits?  Yes  No Please indicate which of the following non-cash benefits have you received over the last 30 days. (You may use “All” if all household members receive the benefit) Start Date Amount (optional) Supplemental Nutrition Assistance Program (Food Stamps)  Yes No If Yes, Household Members: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)  Yes No If Yes, Household Members: TANF child care services  Yes No If Yes, Household Members: TANF transportation services  Yes No If Yes, Household Members: Other TANF-Funded Services  Yes No If Yes, Household Members: Other Source (specify):  Yes No If Yes, Household Members:
SubCook_Initial_Intake_Assessment_20181001.docx