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Rent Assistance Program
The purpose of the Friedman Place Rent Assistance Pilot Program is to financially support people who are legally or totally blind and have low incomes so that they may remain and succeed in the community in their own apartment. Subsidizes are no greater than $300 per month and once accepted to the program, the individual may continue receiving subsidies for three years as long as they remain eligible (e.g., income, blindness, active lease, etc.).
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Name
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Street Address
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City (in Cook County)
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Zip Code
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Phone Number
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Date of Birth
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Do you currently live in Cook County?
Are you legally or totally blind?
Do you currently rent an apartment, house, or room (as opposed to a subsidized housing, long-term care, or other residential program)?
What type of residence are you living in?
If you chose "Other Type of Residence", please describe
Your answer
Are you receiving any type of rent or housing subsidies such as a Housing Voucher (Section 8), etc. or are you living in any type of housing or residential program?
Do you have a valid lease?
If you said "Not sure", please describe
Your answer
Have you been served with an eviction notice for your current apartment?
Have you been leasing your place for at least three months?
Is your annual income at or below the following amount (depending in how many are in your household)? $24,980 for a one person household; $33,820 for a two person household; $42,660 for a three person household; $49,200 for a four person household
What is your gender (for statistical purposes only)
Approximately how long have you been legally or totally blind (for statistical purposes only)
What are the sources of your income?
If you chose "other", please describe
Your answer
Do you understand that you will need to provide documents like a lease, tax returns, pay statements, award letters, bank statements, etc.
Do you agree to notify Friedman Place if your income or housing conditions change, and will provide whatever documentation Friedman Place requests in order to confirm the changes?
Do you agree that all the information that you have and will provide to Friedman Place is true and correct?
Do you understand that the subsidy checks will be written only to the landlord as identified on the Lease, although they can be mailed to you so you can submit it to the Landlord along with your own check at the same time if you would like?
Additional information that you believe will be helpful:
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Applicant Signature & Date
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