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HOUSING PROBLEM SOLVING FUND INVOICE
Date
Entity/Program
Requesting Agency Information
Partner Agency
Housing Resource Specialist name
Housing Resource Specialist Email
Client Information
Client HMIS ID
Client iCarol ID
Client Name
Client Address
Please provide client address if payment will be made to a landlord or utility.
Participant Eligibililty
I Certify that I am seeking emergency assistance via the Coordinated Entry System
Housing Status
At Risk of Homelessness
Category 2: At Imminent Risk of Homelessness
Category 3: Youth and Families Homeless Under Other Federal Definitions
Category 4: Fleeing or Attempting to Flee Gender-Based Violence
Other Category: Facing Forward only
At Risk of Homelessness (check all)
My total household income is below 30% of AMI (see below)
I do not have sufficient resources or support networks, e.g. family, friends, faith-based or other social networks, immediately available to prevent me from moving to an emergency shelter or other literally homeless situation
I meet one or more of the following conditions (check all that apply):
Has moved because of economic reasons two or more times during the 60 days immediately preceding the application for homelessness prevention assistance;
Is living in the home of another because of economic hardship;
Has been notified in writing that their right to occupy their current housing or living situation will be terminated within 21 days after the date of application for assistance;
Lives in a hotel or motel and the cost of the hotel or motel stay is not paid by charitable organizations or by Federal, State, or local government programs for low-income individuals;
Lives in a single-room occupancy or efficiency apartment unit in which there reside more than two persons or lives in a larger housing unit in which there reside more than 1.5 persons reside per room, as defined by the U.S. Census Bureau;
Is exiting a publicly funded institution, or system of care (such as a health-care facility, a mental health facility, foster care or other youth facility, or correction program or institution).
Category 2 Homelessness: An individual or family who will imminently lose their primary nighttime residence, provided that (check all):
My primary nighttime residence will be lost within 14 days of the date of application for homeless assistance;
I have no subsequent residence identified; and
I lack the resources or support networks, e.g., family, friends, faith-based or other social networks needed to obtain other permanent housing;
Category 3 Homelessness: Unaccompanied youth under 25 years of age, or families with children and youth, who are homeless under other federal definitions, and (check all):
I have not had a lease, ownership interest, or occupancy agreement in permanent housing at any time during the 60 days immediately preceding the date of application for homeless assistance;
I have experienced persistent instability as measured by two moves or more during the 60-day period immediately preceding the date of applying for homeless assistance; and
I can be expected to continue in such status for an extended period of time because of chronic disabilities, chronic physical health or mental health conditions, substance addiction, histories of domestic violence or childhood abuse (including neglect), the presence of a child or youth with a disability, or two or more barriers to employment, which include the lack of a high school degree or General Education Development (GED), illiteracy, low English proficiency, a history of incarceration or detention for criminal activity, and a history of unstable employment.
Category 4 Homelessness: Fleeing or attempting to flee gender-based violence, including (check all):
I am fleeing, or is attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to violence against myself or a family member, including a child, that has either taken place within my or my family's primary nighttime residence or has made the me or my family afraid to return to their primary nighttime residence;
I have no other residence; and
I do not have the resources or support networks, e.g., family, friends, faith-based or other social networks, to obtain other permanent housing.
Error
For additional information or larger households, see here:
https://www.chicago.gov/city/en/depts/doh/provdrs/renters/svcs/ami_chart.html
Household Size
Total Household Income (annual)
Notes:
Head of Household Signature (type here)
Date
Housing Resource Specialist Signature (type here)
Date
Page 2
Payment Information
Pay directly to landlord.
Pay directly to supplier or other vendor.
Submit one invoice per vendor.
Reimburse agency (enter Agency info as Supplier/Payee below).
Supplier Information
Supplier/Payee Name
EIN # (for Landlords only)
Supplier/Payee Address Line 1
Supplier/Payee Address Line 2
Supplier/Payee
City
Supplier/Payee
Country
Please select...
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Supplier/Payee
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Supplier/Payee
Provinces
Please select...
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Supplier/Payee
Postal Code
Supplier/Payee
State or Province
Request Payment
To add more than one Type of Assistance
for the same Client and Agency Reimbursement
, use the link below this box to
ADD ANOTHER PAYMENT REQUEST.
Type of Expense - (Required Document) - Accounting Code
Please select...
Security Deposit (A, B, C, E) 57200
Move In Fee (A, B, C, E) 57640
Rent Assistance (A, B, C, E) 57100
Rent Arrears (A, B, C, E, F) 57110
Application Fees (A, D, E) 57620
Utility Assistance (A, B, D, E) 57300
Utility Arrearage (A, B, D, E) 57350
Moving Assistance (A, D, E) 57450
Storage Fee (A, D, E) 57400
Relocation Assistance – Travel (A, D, E) 57682
Relocation Assistance – Food (A, D, E) 57682
Relocation Assistance – Essential Household Item (A, D, E) 57670
Transportation Assistance (A, D, E) 57682
REQUIRED DOCUMENT
Attach the document(s) based on the code listed in the Type of Assistance
(A) Participant Eligibility Form
(B) Signed Lease
(C) W-9
(D) Proof of Expense
(E) Housing Plan
(F) Five Day Notice
Attach Document(s) Showing Requested Amount for this Item
Client's Utility Account Number
Amount Requested
$
Description/Explanation
For All Chicago Use
Memo/Description
Total Requested
$
Reference Number
Contact Information
