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GAP Online Application
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GAP Online Application
Name
(Required)
First
Middle
Last
Phone
(Required)
Alt. Phone
Email
A. Do you live in one of the following counties? Adams, Brown, Cass, Hancock, Henderson, McDonough, Morgan, Pike, Schuyler, Scott, or Warren?
(Required)
Yes
No
B. Is your housing situation "couch surfing" or "doubled up" with friends, family, and/or someone else?
Yes
No
******* Questions A and B above must be YES in order to qualify for this program. ********
Certifications
(Required)
I certify that no one in my household is required to register as a sex offender in any state.
I certify that in the last 5 years, no one in my household has been convicted of and/or does not have a pending charge for a violent crime (such as, but not limited to felony OR misdemeanor domestic violence, assault, battery, kidnapping, arson, etc).
***** Those with convictions or pending charges described above are not eligible for this program. ******
C. Did someone in your household lose income as a direct result of COVID-19 (reduced hours, laid off, etc) and/or have a medical condition that increases the risk of COVID-19, as stated by the CDC? (Documentation of loss of income and/or diagnosis is required.) If yes, explain:
(Required)
Yes
No
C. Explain
(Required)
D. Did you have a major life event in the last 12 months that is causing or will likely cause housing problems? Y / N If yes, explain:
(Required)
Yes
No
D. Explain
(Required)
E. Over the past year, how many months have you been couch surfing/doubled up?
(Required)
F. Have you been asked to leave the place you're staying within the next 30 days? If yes, explain:
(Required)
Yes
No
F. Explain
(Required)
G. Does anyone in your household have a disability or condition that makes getting or keeping stable housing difficult, such as substance use, mental health conditions, HIV/AIDs, or a physical or developmental Y / N disability? If yes, explain:
(Required)
Yes
No
G. Explain
(Required)
H. Is anyone in your household currently pregnant?
(Required)
Yes
No
I. Are you trying to escape physical domestic violence including sexual violence?
(Required)
Yes
No
J. Have you ever been enlisted in the military?
(Required)
Yes
No
K. Are you or your spouse/partner employed or have another regular source of income?
(Required)
Yes
No
In the last year, did your household have any of the following types of income?
Employment
Unemployment / worker's compensation
SSI / SSDI (disability)
VA income (disability or retirement)
Child support
TANF cash assistance
SNAP / LINK food assistance
Other Income
Employment - How long have you had this income?
Unemployment / worker's compensation - How long have you had this income?
SSI / SSDI (disability) - How long have you had this income?
VA income (disability or retirement) - How long have you had this income?
Child support - How long have you had this income?
TANF cash assistance - How long have you had this income?
SNAP / LINK food assistance - How long have you had this income?
Other Income - How long have you had this income?
Employment - Will you lose this income in the next 60 days?
(Required)
Yes
No
Unemployment / worker's compensation - Will you lose this income in the next 60 days?
(Required)
Yes
No
SSI / SSDI (disability) - Will you lose this income in the next 60 days?
(Required)
Yes
No
VA income (disability or retirement) - Will you lose this income in the next 60 days?
(Required)
Yes
No
Child support - Will you lose this income in the next 60 days?
(Required)
Yes
No
TANF cash assistance - Will you lose this income in the next 60 days?
(Required)
Yes
No
SNAP / LINK food assistance - Will you lose this income in the next 60 days?
(Required)
Yes
No
Other Income - Will you lose this income in the next 60 days?
(Required)
Yes
No
M. Type in your household gross income. Points will be assigned based on household gross (before tax) annual income.
(Required)
N. List each household member's information below beginning with the head of household. Include the legal custody arrangement for each child.
(Required)
First Name
Last Name
Age
DOB
Gender Indentity
Custody: full, shared, foster care, etc
Add
Remove
Click on the + symbol on the right to add another household member
Households are placed into available units based on points, with the highest scoring applicant being placed first.
Backup documentation is required (see examples on the document checklist).
Neither this agency nor its funders discriminate based on any Federally protected class. Sexual offenses and violent criminal history may cause a household to be ineligible. Applicants who are denied placement may appeal by calling 217-221-9922.
I certify that all information documented on this application is true and accurate to the best of my knowledge.
(Required)
I certify that all information documented on this application is true and accurate to the best of my knowledge.
Digital Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Documentation Checklist
Documentation of the following must be submitted
at the same time as the application*.
Please bring all documents to 639 York, Suite 202 Quincy, IL or email to TaylorFlint@ywcaquincy.org
Adams County residency: submit only one
Examples of proof of residency include:
Drivers license or State ID
Most recent utility bill
Pay stub
Diagnosis / disability: submit one form of documentation per diagnosis or disability
Examples of proof of diagnosis or disability include:
SSDI check or letter
Medical record with name of condition
Substance use treatment or counseling record with name of condition
Mental health treatment or counseling record with name of condition
Sources of Income: submit one proof of income for each income type
Examples of proof of income include:
SSI or SSDI check or letter
Pay stub
Most recent W2 or taxes
TANF cash assistance letter or statement
Child support court order
Unemployment award letter
VA retirement or disability award letter or pay stub
Veteran Status: submit one
Examples of proof of veteran status include:
DD214, regardless of discharge type
Pregnancy: submit only one for each pregnant person in the household
Examples of proof of pregnancy include:
Medical record
Document from a pregnancy resource center if you completed a pregnancy test there
Major life event: submit as many as needed to fully and accurately describe the impact of the event on your housing
Examples of proof of major life event will depend on the event. Remember, only report life events from the last 12 months that have caused or will cause housing problems.
Medical record
Obituary
Court record
Employment termination documentation
Divorce decree
*Further documentation or clarification may be required upon request. Those fleeing physical domestic violence including sexual violence may submit their backup documentation later.
Phone
This field is for validation purposes and should be left unchanged.
