2. Lincolnwood's Assist-a-Family Program Application

4. The Village launched the Assist-a-Family Program (previously known as the Harice Leavitt Memorial Fund) to support Lincolnwood residents in financial distress who need assistance with their water and utility bills. Funded by public donations, the Assist-a-Family Program subsidizes water and sewer bills for qualifying residents. 

   To qualify for the Assist-a-Family Program, your household income must be reported and no greater than 200% of the Federal Poverty Line (FPL). FPL guidelines are available here.

   Qualifying residents are eligible to receive up to $100 to supplement their water and sewer bill payment to the Village in any one instance. An instance is defined as the application of money from the program used towards an outstanding water and sewer bill in an amount exceeding $100. If a qualifying resident receives a subsidy then moves to the end of the queue,  it is considered an instance. No qualifying resident may receive more than $200 in a calendar year.

   Please note, completion and submittal of this form does not guarantee assistance. If approved for financial assistance, an email will be sent regarding next steps.

   A paper application can be downloaded and completed here. 

6. Today's Date*
   Today's Date
8. First Name*
9. Last Name*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Email Address*
20. Monthly Gross Income (Before Taxes)*

    Household income must be reported and no greater than 200% of the Federal Poverty Line (FPL).

22. Attach your ComEd or Nicor Bill*
24. Household Members

    List all adults and children who live with you full time.

26. First Name
27. Last Name
28. Adult or Minor
    -- Select One --AdultMinor
30. First Name
31. Last Name
32. Adult or Minor
    -- Select One --AdultMinor
34. First Name
35. Last Name
36. Adult or Minor
    -- Select One --AdultMinor
38. First Name
39. Last Name
40. Adult or Minor
    -- Select One --AdultMinor
42. First Name
43. Last Name
44. Adult or Minor
    -- Select One --AdultMinor
46. First Name
47. Last Name
48. Adult or Minor
    -- Select One --AdultMinor
50. First Name
51. Last Name
52. Adult or Minor
    -- Select One --AdultMinor
56. Terms and Conditions*

    By submitting the application, you certify that the information provided on and in connection with the form is true and correct to the best of your knowledge. You also understand that any false statements or deliberate omissions on this form may disqualify you from all future Harice Leavitt Memorial Fund benefits.

    1. I Agree
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field