CPAH Inclusionary Rental Pre-Application

Please complete all sections as fully as possible.

All fields with an asterisk (*) are required.

GENERAL





Does anyone in your household reside with you less than full-time?
YesNo

Do you currently:*
RentOwn

Please indicate which communities are of interest to you:
Highland ParkLake Forest (62+)EvanstonEvanston (55+)Northbrook

Do you work in one of these communities?
Highland ParkLake ForestEvanstonNorthbrook

HOUSEHOLD MEMBER 1 EMPLOYMENT & INCOME

Are you self-employed?* YesNo




Report Below Numbers as Gross Income (Income BEFORE Taxes)








HOUSEHOLD MEMBER 2 EMPLOYMENT & INCOME

Are you self-employed?* YesNo




Report Below Numbers as Gross Income (Income BEFORE Taxes)








Are there additional household members who have income?
YesNo
If yes, please indicate their name and current gross monthly income.



HOUSEHOLD ASSETS (Please add together and note the assets of all household members)






OTHER FUNDS AND SUPPORTS

Do you have a housing voucher? YesNo
If yes, please provide who the voucher is with (Lake County Housing, Cook County Housing, Chicago Housing Authority, etc.)
If you are the owner/beneficiary of an ABLE account, what is the current balance? $ How much is deposited in this account each month? $
Are you the beneficiary of a Special Needs Trust? yesno
If yes, what is the current balance? $
Do you anticipate receiving any one-time or recurring gifts? yesno
If yes, please describe.