Fillable COUNTY OF KANE Application for Veterans Assistance (Kane County, Illinois)

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COUNTY OF KANE Application for Veterans Assistance (Kane County, Illinois)

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1
COUNTY OF KANE
VETERANS ASSISTANCE COMMISSION
Application for Veterans Assistance
SECTION I: INSTRUCTIONS
Use these instructions, the attached Notice of Rights and Responsibilities, and the attached application to apply for Veterans Assistance.
Section II of this form notifies you of your rights and responsibilities as it applies to the Veterans Assistance Program. Please answer all
questions in Sections III through Section VIII of this application. Be sure you, and if applicable your spouse, signs this application before
you submit it. When submitting this application, be sure to include a copy of each one of your DD-214’s (military separation papers), a
copy of your marriage certificate if applicable, a copy of dependency documents such as birth certificates or adoption decrees for children
if applicable, a copy of your government-issued photo identification card with a current Kane County address, and a copy of your
spouse’s government-issued photo identification card with a current Kane County address if applicable. Submit your application and
those documents in person during normal business hours, by mail, or by fax to:
Veterans Assistance Commission of Kane County
719 South Batavia Avenue, Building A
Geneva, Illinois 60134-3077
Fax: (630) 232-5403
If you mail or fax your application, be sure to call our office at (630) 232-3550 to ensure that we received it. If utilizing public
transportation to bring your application to our office, Pace Bus Routes 801 and 802 in addition to their local “Call-n-Ride” and “Dial-a-
Ride” programs serve locations near our office. Metra’s Union Pacific West Line’s Geneva Station is located a block from our location.
For more information about public transportation options please call the Regional Transportation Authority at (312) 836-7000.
SECTION II: NOTICE OF RIGHTS AND RESPONSIBILITIES
Applicant’s Responsibilities: You have the responsibility to remain compliant with Federal and State Laws and regulations in addition
to the regulations provided in the Veterans Assistance Program Manual. You are also obligated to:
•
Disclose all required information during the application process. Failure to disclose required information or misrepresenting
information is tantamount to perjury and may be subject to civil and/or criminal prosecution for violating state law including but not
limited to 720 ILCS 5/16-1 and 720 ILCS 5/17-6.
•
Immediately report any changes in household income, job status, residence, death, or contact information. You are obligated by law to
keep the Commission current with all information that affects your right to Veterans Assistance. Failure to promptly disclose changes
in required information or misrepresenting information is tantamount to perjury and may be subject to civil and/or criminal prosecution
for violating state law including but not limited to 720 ILCS 5/16-1 and 720 ILCS 5/17-6.
•
Actively pursue all other applicable programs that provide assistance. It is the intent of the Commission that Veterans Assistance
should promote the welfare of eligible recipients through this program in addition to any other program(s) that may assist you. This
program is not intended to provide long-term assistance to sustain an individual or their family.
•
Manage your income in a responsible manner. The Commission cannot be expected to support individuals that habitually exhibit bad
financial planning or misuse of their income. Markers such as unexplained deposits, large withdrawals, exorbitant expenses, and
unexplained travel in your records will be flagged for clarification as to the necessity of such transactions.
Right to Notification of Rights: You have the right to a summary of rights as prescribed in the Veterans Assistance Program Manual.
Section II of this application constitutes our notice to you of your rights.
Right of Non-Discrimination: You have the right to be treated by the Commission in a fair and impartial manner. You will not be
discriminated against or denied assistance by the Commission because of your race, color, national or ethnic origin, age, religion,
disability, gender, sexual orientation, gender identity and expression, or political affiliation.
Continued on Next Page. Do Not Submit this Page, Keep it for Your Records.
JACOB A. ZIMMERMAN
Superintendent
COUNTY GOVERNMENT CENTER
719 South Batavia Avenue, Building A
Geneva, Illinois 60134-3077
Phone: (630) 232-3550
Fax: (630) 232-5403
www.countyofkane.org/pages/veterans.aspx
2
Continued from Previous Page
Right of Confidentiality:
•
Your case file and information are subject to strict confidentiality. Your case file may not be released without your express written
consent unless the release is otherwise specifically authorized by federal, state, or local laws and regulations, or as prescribed in the
Veterans Assistance Program Manual.
•
Your case file is the property of the Commission and may be released to you upon your written request. Information contained in your
case file that is exempt from disclosure under federal, state, or local law may not be released.
•
To further protect your case file, a unique “Film Number” will be assigned to you for our use.
•
Your case file may be released if specifically requested by the Kane County Board Chairman or his/her designated officer pursuant to
330 ILCS 45/9 or the Kane County Auditor pursuant to 55 ILCS 5/3-1005 to maintain a continuous internal audit of the operations and
financial records of the officers, agents, or divisions of the county.
•
In a judicial proceeding, except those directly concerned with the administration of Public Aid, or those in which an applicant is a party
thereto, the above information is considered to be privileged communications, defined as "a communication between parties to a
confidential relationship such that the person receiving the communication cannot be legally compelled to disclose it as a witness."
•
Your case files will be made available when subpoenaed subject to the consent of the Kane County State’s Attorney or his or her
designee.
•
If your name and/or address is furnished to other governmental agencies, those agencies must adopt regulations necessary to prevent
their publication or use for purposes not directly connected with the administration of assistance under the Illinois Public Aid Code.
Right of Consideration:
•
Upon the receipt of your completed and signed application, we will process your application in a timely manner. A completed
application is defined as the completion of this application form in its entirety which is signed and submitted with the veteran’s
separation papers, dependency documents, and a valid government-issued photo identification card which lists your current address.
•
In the course of processing the application, Commission staff subject to the provisions of this manual, may be required to request
additional documentation regarding income, net worth, employment, military service status, school attendance, criminal history,
medical treatment, and government benefits to determine eligibility. Commission staff will notify you of any additional required
documentation by writing and in a timely manner.
•
To allow you sufficient time to obtain any required documentation, your assessment will be scheduled no sooner than 14 days from the
time we respond to your application. You can request a sooner assessment if you have obtained all required information. You may
also reasonably extend your assessment appointment in order to obtain necessary documentation. Any request made by you to reduce
or extend your assessment time will be noted in your case file.
•
The Commission has a duty to adjudicate every complete application received and to notify you of the decision of your application or
renewal assessment. A decision will not be rendered if you withdraw from further assistance. Any withdrawal shall be made in writing
and signed by you.
Right of Inclusion:
•
Upon your request, you may receive a copy of the forms that you signed at the conclusion of the application or assessment process.
•
We will furnish you, as much as practicable, the addresses and locations of any other agencies and organizations that might be able to
provide additional help with your individual circumstances. You have a responsibility to pursue other resources that can enhance your
welfare. If you appear to be eligible for other government assistance, you will be referred to the respective agencies. If you fail to
pursue those benefits, you will lose eligibility for Veterans Assistance until you demonstrate compliance.
•
A paper copy of the Veterans Assistance Program Manual is available for review at our office during normal business hours.
Right of Review:
•
If your application or assessment was denied, you will be granted the right to present additional evidence to Commission staff that may
have a bearing on your eligibility if you request.
•
If you are dissatisfied with a decision made by Commission staff, you have the right to file an appeal. Additional information about
appeals will be included in our decision to you.
Right of Notification: You have the right to receive notification of our decision in regards to your eligibility for Veterans Assistance.
Notification shall be by a Notice of Decision which shall be given to you in person or delivered to you through the U.S. Postal Service.
The Notice of Decision will include the decision made, reasons for the decision, relevant statute or manual citation, and a notice to you of
your right to appeal our decision.
Right to Appeal: If you disagree with any part of the Notice of Decision issued to you, you have the right to appeal that decision.
Additional information about appeals will be included in the Notice of Decision.
Do Not Submit this Page, Keep it for Your Records
3
SECTION III: APPLICANT AND CONTACT INFORMATION
VAC DATE STAMP
(DO NOT WRITE IN THIS SPACE)
1. VETERAN’S NAME (Last, first, middle)
2. VETERAN’S SOCIAL SECURITY NUMBER
3. VETERAN’S DATE OF BIRTH (Month / Day / Year)
4. APPLICANT’S NAME, if different from 1 (Last, first, middle)
5. APPLICANT’S SOCIAL SECURITY NUMBER
6. APPLICANT’S DATE OF BIRTH (Month / Day / Year)
7B. APT. NUMBER
9A. HOME TELEPHONE NUMBER
7C. CITY
7D. ZIP CODE
9B. CELLULAR TELEPHONE NUMBER
8B. APT. NUMBER
9C. WORK TELEPHONE NUMBER
8C. CITY
8D. STATE
8E. ZIP CODE
9. IS ANYONE IN YOUR HOUSEHOLD ATTENDING OR PLANNING TO ATTEND COLLEGE:
☐ YES ☐ NO (If “no,” skip to Section IV. If “yes,” mark all that apply.) ☐ YOURSELF ☐ SPOUSE ☐ CHILD
SECTION IV: APPLICANT’S DEPENDENCY STATUS
NOTE: If married, you should provide a copy of your marriage certificate with this application. If widowed, you should provide a copy of your spouse’s death certificate
with this application. If divorced, you should provide a copy of your divorce decree with this application. If separated, you should provide a copy of your legal separation
papers with this application. If you need help obtaining these documents, call the County office where the documents were filed.
10. WHAT IS YOUR CURRENT MARITAL STATUS?
(If “Married,” complete Boxes 10 through
☐ MARRIED ☐ WIDOWED ☐ DIVORCED ☐ LEGALLY SEPARATED ☐ NEVER MARRIED 15 otherwise skip to Box 16.)
11. WHEN WERE YOU MARRIED? (Month / Day / Year)
12. WHERE DID YOU GET MARRIED? (City, State or Country)
13. SPOUSE’S NAME (Last, first, middle)
14. SPOUSE’S SOCIAL SECURITY NUMBER
15. SPOUSE’S DATE OF BIRTH (Month / Day / Year)
16. DO YOU LIVE WITH YOUR SPOUSE?
☐ YES ☐ NO
NOTE: If you have dependent children you should provide birth certificates and/or adoption decrees for all of your dependent children. If you need help obtaining these
documents, call the County office where the documents were filed.
17. DO YOU HAVE ANY DEPENDENT CHILDREN THAT RESIDE WITH YOU? (If “no,” skip to Section V)
☐ YES ☐ NO
CHECK EACH APPLICABLE CATEGORY
BIOLOGICAL
ADOPTED
STEPCHILD
RESIDES
WITH YOU
EMPLOYED
RECEIVING
BENEFITS
NAME OF CHILD
(Last, first, middle)
DATE OF BIRTH
(Month / Day / Year)
PLACE OF BIRTH
(City, State or Country)
SOCIAL SECURITY
NUMBER
☐ ☐ ☐ ☐ ☐ ☐
☐ ☐ ☐ ☐ ☐ ☐
☐ ☐ ☐ ☐ ☐ ☐
☐ ☐ ☐ ☐ ☐ ☐
CONTINUED ON NEXT PAGE
IL
4
SECTION V: ACTIVE DUTY SERVICE INFORMATION
NOTE: You must submit a DD-214 or equivalent document for each period of active duty service. If you do not have your DD-214, call our office for help obtaining one.
BRANCH OF SERVICE
DATE ENTERED ACTIVE DUTY
(Month / Day / Year)
DATE SEPARATED FROM ACTIVE DUTY
(Month / Day / Year)
CHARACTERIZATION OF SERVICE
SECTION VI: EMPLOYMENT INFORMATION
18. ARE YOU EMPLOYED?
☐ YES ☐
NO If “Yes,” state the name of your employer and skip to Box 21:____________________________________________________________________
19. WHO WAS YOUR LAST EMPLOYER?
20. WHAT WAS THE LAST DATE YOU WERE EMPLOYED? (Month / Day / Year)
21. IS YOUR SPOUSE EMPLOYED?
☐ YES ☐
NO If “Yes,” state the name of your spouse’s employer and skip to Section VII:_________________________________________________________
22. WHO WAS YOUR SPOUSE’S LAST EMPLOYER?
23. WHAT WAS THE LAST DATE YOUR SPOUSE WAS EMPLOYED?
(Month / Day / Year)
SECTION VII: FINANCIAL INFORMATION
24A. LIST ALL MONTHLY INCOME FOR YOU AND YOUR SPOUSE
24B. LIST ALL ASSETS YOU AND YOUR SPOUSE OWN
SOURCE OF INCOME
YOURSELF
YOUR SPOUSE
ASSET
YOURSELF
YOUR SPOUSE
EMPLOYMENT
$ $
SAV
INGS ACCOUNTS
$ $
SOCIAL SECURITY
$ $
CHECKING
ACCOUNTS
$ $
VA BENEFITS
$ $
STOCKS, BONDS, OR
MUTUAL FUNDS
$ $
UNEMPLOYMENT
$ $
REAL ESTATE (Other
than primary residence)
$ $
RETIREMENT PENSION
$ $
AUTOMOBILES, HOW
MANY TOTAL:_______
$ $
CHILD SUPPORT
$ $
TRAILERS, BOATS,
OR CAMPERS
$ $
OTHER:
$ $
BUSINESS THAT YOU
OWN
$ $
OTHER:
$ $
OTHER:
$ $
SECTION VIII: APPLICATION CERTIFICATION AND SIGNATURE
Please ensure that your application is complete and that you, and if applicable your spouse, reads and signs this certification. By signing
below you, and if applicable your spouse, certify that:
1. All of the information listed on this application is true and correct to the best of your knowledge and belief.
2. You understand that if you did not provide full or correct information on this application you may be required to repay any Veterans
Assistance benefits received either voluntarily, through court order, or through the Illinois Local Debt Recovery Program.
3. You understand that if you provide fraudulent information to obtain Veterans Assistance benefits you will be reported to the Kane County
Sherriff’s Office for investigation and prosecution.
4. You have received a Notice of Rights and Responsibilities which are listed in Section II of this application.
5. You authorize the release of any information from any person, entity, organization, agency, service provider, or employer that the Veterans
Assistance Commission of Kane County determines is required to make a determination on your application for Veterans Assistance.
APPLICANT’S SIGNATURE
DATE SIGNED
SPOUSE’S SIGNATURE
DATE SIGNED
STOP, BEFORE YOU SUBMIT THIS APPLICATION, DID YOU ATTACH A COPY OF THE FOLLOWING DOCUMENTS FOR YOU AND YOUR DEPENDENTS:
☐ DD-214’s ☐
SOCIAL SECURITY CARDS ☐
PHOTO ID’s ☐
DEPENDENCY DOCUMENTS (Marriage, birth, divorce, death, adoption, etc.)
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5
Assistance Programs Through Other Organizations
You may qualify for other assistance programs that are administered by other government, non-profit, or for-profit
organizations. We have listed some of those programs on the following pages. None of these programs are
administered by the Veterans Assistance Commission of Kane County and we do not have any input in the processing
or decision making of any of these programs. These programs are subject to change at any time, please check with
the organization for current information. Please note that it is not an exhaustive list of all programs that you may
qualify for.
Two Rivers Head Start Agency - Community Services Block Grant: This program is designed to provide a range of
services which assist eligible clients who live in Kane County to attain skills, knowledge, and motivation necessary to
achieve self-sufficiency. The program also may provide clients with immediate life necessities such as food, shelter,
or medicine.
Two Rivers Head Start Agency Two Rivers Head Start Agency
1661 Landmark Road 418 Airport Road, Suite B
Aurora, Illinois 60506 Elgin, Illinois 60123
(630) 264-1444 (847) 717-6048
Midwest Shelter for Homeless Veterans - Supportive Services for Veterans Families: This program provides
services to low-income veterans and their families who are homeless or at-risk. The program is funded through the
U.S. Department of Veterans Affairs to help stabilize housing through the provision of short-term financial assistance,
case management, and supportive services. The program is provided throughout the counties of DuPage, Grundy,
Kane, Kendall, and Will.
Midwest Shelter for Homeless Veterans
433 South Carlton Avenue
Wheaton, Illinois 60187
(630) 871-8387
Midwest Shelter for Homeless Veterans - Veteran Employment Program: This program is a unique opportunity for
unemployed and underemployed Veterans to achieve success in finding rewarding and lasting employment. They
also help veterans enhance their ability to access a multitude of other services ranging from housing to material goods
to ensure a firm footing on their path to success. Participants in this program receive services specifically tailored to
their individual needs.
Midwest Shelter for Homeless Veterans
433 South Carlton Avenue
Wheaton, Illinois 60187
(630) 871-8387
Continued on Next Page. Do Not Submit this Page, Keep it for Your Records.
6
Midwest Shelter for Homeless Veterans - Freedom Commissary: The Freedom Commissary is the “free” thrift
store designed to meet the clothing, household and basic needs of veterans and their families. The store serves
veterans of all eras and branches and eligibility is based on need. The program is designed to provide for veterans and
their families to help prevent and end homelessness and to promote the development of employment skills. Veterans
are able to access the Commissary for items such as basic and work related clothing, household goods, hygiene
products, cleaning products, paper goods, furniture, and appliances.
Midwest Shelter for Homeless Veterans
433 South Carlton Avenue
Wheaton, Illinois 60187
(630) 871-8387 x617
Commonwealth Edison - ComEd Helps Activated/Veteran Military Personnel: CHAMP is a financial-assistance
program that offers an optional package of benefits to qualified military personnel who reside within ComEd’s service
territory and have fallen behind on their electric bill.
ComEd Helps Activated/Veteran Military Personnel (CHAMP)
Attention: ComEd/Revenue Management
PO Box 2550
Chicago, Illinois 60690
(888) 806-2273
Nicor Gas – Crisis Situations and Veterans: Eligible customers who are Veterans can receive a maximum grant up to
$200. Upon applying for this grant it will require company approval and customers must meet income guidelines and
that do not exceed 300% of the Federal Poverty Level. To apply, visit your local Salvation Army office in person. If
you're approved for a Sharing Grant, the Salvation Army will make payments to Nicor Gas on your behalf.
Salvation Army Gas Sharing Grant Salvation Army Gas Sharing Grant Salvation Army Gas Sharing Grant
437 East Galena Boulevard 1710 South 7
th
Avenue 316 Douglas Avenue
Aurora, Illinois 60505 Saint Charles, Illinois 60174 Elgin, Illinois 60120
(630) 897-7265 (630) 377-2769 x209 (847) 741-2304 x13
U.S. Department of Health and Human Services - Low Income Home Energy Assistance Program: This program
is designed to assist eligible households pay for winter assistance on utility bills. LIHEAP provides a one-time benefit
for heat and electric bills. The benefit amount is determined by income, household size, and heating fuel type.
Community Contacts Community Contacts
1700 North Farnsworth Avenue, Room 13 100 South Hawthorne Street
Aurora, Illinois 60505 Elgin, Illinois 60123
(847) 697-4400 (847) 697-4400
Continued on Next Page. Do Not Submit this Page, Keep it for Your Records.
7
U.S. Department of Veterans Affairs - Housing and Urban Development/Veterans Affairs Supportive Housing:
This program provides permanent housing for eligible homeless veterans who are single or eligible homeless veterans
with families. The program is developed for the homeless veteran, so eligible veteran families must include the
veteran.
Edward Hines Jr. VA Medical Center
Health Care for Homeless Veterans
5000 South Fifth Avenue
Building 228, Fourth Floor, Room 4101
Hines, Illinois 60141
(708) 202-4961
Illinois Department of Human and Family Services - Temporary Assistance for Needy Families (TANF): This
program is for families with children and pregnant women who need temporary cash assistance. Those receiving
TANF also receive medical assistance. Most TANF families also receive SNAP benefits to buy food.
Illinois Department of Human and Family Services Illinois Department of Human and Family Services
361 West Old Indian Trail 700 South State Street
Aurora, Illinois 60506 Elgin, Illinois 60123
(630) 844-7400 (847) 931-2700
Illinois Department of Human and Family Services - Supplemental Nutrition Assistance Program: This program
helps low-income people and families buy the food they need for good health. Benefits are provided on the Illinois
Link Card - an electronic card that is accepted at most grocery stores. The program is managed by the Food and
Nutrition Service of the United States Department of Agriculture. The Department of Human Services administers the
program in Illinois.
Illinois Department of Human and Family Services Illinois Department of Human and Family Services
361 West Old Indian Trail 700 South State Street
Aurora, Illinois 60506 Elgin, Illinois 60123
(630) 844-7400 (847) 931-2700
Township - General Assistance: General Assistance is a locally administered welfare program which provides
monthly financial assistance to persons who do not have adequate income or resources to provide for their own basic
needs. To qualify, the individual must meet certain financial and residential criteria, and be ineligible for any other
state or federal assistance programs.
Contact your local Township Supervisor for more information.
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COUNTY OF KANE Application for Veterans Assistance (Kane County, Illinois)

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Completed 6 April 2021

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