Daca Renewal Eligibility Screening Form (Page 3 of 3) in pdf

Daca Renewal Eligibility Screening Form Page 3

Please complete the following questions and submit this entire questionnaire to ILCM.

CONTACT AND INCOME ELIGIBILITY INFORMATION: (Please write clearly)

Complete Name:

________________________________________________________________________

Date of birth:

________________________________________________________________________

Address:

________________________________________________________________________

Phone number(s):

________________________________________________________________________

Indicate whose phone # it is if not yours: _________________________________________________________

Email address:

________________________________________________________________________

Did ILCM assist you in your initial DACA application? Yes_______ No______

How many people live in your household? _____________________________________________

How many adults?: __________

How many children?: ________

What is the monthly income for all working members of your household before taxes?

From employment:

_______________________

From other sources such as cash assistance or child support?: ________________________

SUBMIT THIS FORM TO ILCM

If you would like ILCM’s assistance, please submit this entire DACA renewal eligibility form to ILCM

through one of the methods listed below. Your information will be kept confidential. An ILCM staff

member will contact you to see if we can help you. Please note that we will prioritize cases based on an

applicant’s DACA expiration date. Please note: submission of this form does NOT automatically

make you a client of ILCM.

By Email:

scan and email to

Fax:

Fax to ILCM’s fax number: 651-641-1131

Mail:

ILCM

450 N. Syndicate St.

Suite 200

St. Paul, MN 55104

For more information about ILCM and our services, please see our website:

Daca Renewal Eligibility Screening Form Page 3