Intent to Apply Form

Northeastern Illinois Area Agency On Aging Intent to Apply
PDF version of this form, click here.

Agency Name *-required
Street Address *
		City: State: Zip: *

Mailing Address
		City: State: Zip: *

Contact person *
Phone *
Fax
E-Mail Address *
County *
Applicant's Legal Status		Government Entity Not-for-Profit Corporation - IRC 501(c)3 Tax Exempt Organization - URC 501(a) only Corporation Sole Proprietorship
TIN Number	(Note: Due to security issues, we will call for the organization's federal ID or social security number.)

Suspension from bidding Has the applicant been suspended or barred from bidding by any governmental entity for any length of time during the last five years?
		Yes No
If so, please explain:

Attach a copy of your most recent Annual Report and/or IRS Form 990 or 990EZ. The file may be a MS-Word Doc, PDF, plain text, or ZIP file no larger than 5mb.


Describe how you would use Area Agency on Aging financial assistance support.

Funder	Amount	Contact Name	Phone/Email
Identify current funding sources and provide contact information:
	$
	$
	$
	$
PLEASE PRINT THIS PAGE BEFORE SUBMITTING Once clicking the "Submit" button, this form will be immediately sent to AAOA. If an error is made, simply make the necessary adjustments and re-submit.

Northeastern Illinois Area Agency On Aging Intent to Apply