MCHENRY COUNTY HOUSING AUTHORITY

First Name

Middle Initial

Last Name

Number of people living in your household, including yourself:

Your email

Your phone number

Have you lived in McHenry County for at least all of the past 30 days?
YesNo

Current address

What services are you looking for? (check all that apply):
Emergency rental assistanceMortgage assistancePermanent, affordable rental housingHelp with utility or water bills, or assistance making your home energy efficientHome rehabilitation services (for homeowners)Dental AssistanceOther
If “Other” please explain:

How much gross income (before taxes) does your full household receive right now each month and what are the sources of the income? Include all sources of income, such as wages, Social Security, child support, cash, etc.

Sources of Income (check all that apply):
WagesSocial SecuritySocial Security DisabilityUnemployment benefitsCashOther
If “Other” please explain: