The Center of Concern
Homeless Prevention
Inquiry Form

Mail to: The Center of Concern,      1530 N. Northwest Hwy., Suite 310,       Park Ridge, IL 60068


Date ___________________________


Name ____________________________________________________ Date of Birth ________________


Address ___________________________________City _________________ State ___ ZIP _________

Home Phone __________________ Work Phone ________________ Cell Phone ________________

Referred by __________________________________________________________________________

Have you received assistance from us in the past?   Yes ___   No ___

If yes, date and type of assistance received ______________________


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Marital Status: Single ___ Married ___ Separated ___ Divorced ___ Widowed ___


If married, spouse’s name ____________________________________________________________

Do you have any children? Yes ___ No ___ If yes, names and ages ____________________________

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Are you working? Yes ___ No ___   If not, do you have a source of income? Yes ___ No ___

Source of current income: Unemployment __ Social Security __ Disability __ SSI __ Child Support __

Alimony ___ Cash Assistance ___ Food Stamps ___ Township ___ Other _______

How much income do you receive monthly? ________

What type of assistance are you looking for? Rental ___ Security deposit ___ Mortgage ___ Utility___

How much do you owe? _________________________

For rent, do you have a 5-day notice? ______     Have you gone to court? ______

For utilities, do you have a shut-off notice? ______     Have your utilities been shut off? ______

Briefly describe your current circumstances or situation: _____________________________________

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