Supportive Housing Program
Inquiry Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Do you rent or own your home?
*
Rent
Own
How many adults (anyone over 18 years old) are in the home?
*
How many children are in the home?
*
Have you been a Lycoming County resident for one or more years?
*
Yes
No
Do all adults in your home have sustainable income or do they expect to have income in the next 60 days?
*
Yes
No
Do you have rental/mortgage arrears that are less than $3000?
*
Yes, my rental/mortgage arrears are less than $3,000
My rental/mortgage arrears are greater than $3,000
I do not have rental/mortgage arrears
Do you have any previous evictions?
*
Yes
No
How many previous evictions do you have?
*
Please list the dates (month/year) of all previous evictions.
*
Please explain, in detail, the circumstances which led you to apply for Supportive Housing.
*
Submit
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