Home Accessibility Program
City: _____________________ County: ___________________________ Zip Code: ____________
Phone: (Home) _________________________________ (Work) ____________________________
(Cell) _________________________________ (Email) ____________________________
Annual Household Income: $_____________________________________________________________
You must include anyone 18 yrs. and over living in the household, all parties’ information will be verified.
Family Size: ___________________
Do you receive assistance from an agency funded by the IDOA or IDHS? (ex: SNAP Benefits –IDHS)
IDOA_____ IDHS____ No___ Not sure ___
Illinois Department on Aging Illinois Department of Human Services
List items to be modified _________________________________________________________________
NORTH WEST HOUSING PARTNERSHIP does not discriminate against any applicant on the basis of race,
color, creed, religion, sex, national origin, age, familial status, ancestry, unfavorable military discharge, and marital
status, receipt of governmental assistance or handicap.
In addition, NORTH WEST HOUSING PARTNERSHIP does not discriminate on the basis of handicapped status
in the admission or access to, or treatment or employment in its federally assisted programs and activities.
Please return this form via mail: ATTN: Michelle Hill-Program Manager
North West Housing Partnership
1701 E. Woodfield Rd, Suite 203, Schaumburg, IL 60173
If you have any questions about this pre-application, please call 847.969.0561