Master Leasing Program Application

Master Leasing Program

Application
Applicant must complete STEP General Registration, Household form, Service Assessment, and provide proof of income (if applicable). If an applicant does not provide all required information, eligibility determination will not occur until all documents are received.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you been a resident of Lycoming County for 12 months?*

YesNo
Are you currently experiencing homelessness or living within a shelter?*

Yes, I am currently experiencing homelessnessYes, I am currently living within a shelterNo
Phone Number*
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.

Household Composition
Are you the Head of Household?*

YesNo
Total number of persons living in the home:*
Does a household member have a permanent physical, mental, or emotional disability?*

YesNo
Is handicapped accessibility required?*

YesNo
Please explain.

Residence Information
Briefly explain your current housing situation - where you are living and why you need housing.*
Are you or any of your household members currently working with or receiving services from other agencies?*

YesNo
Please expand sections below to list agencies you or other household members are receiving services from.

Agency #1
Agency #1

Agency #2
Agency #2

Agency #3
Agency #3

Agency #4
Agency #4

Agency #5
Agency #5

Do you need to list any other agencies?*

YesNo
Please list them here, along with the contact person, phone number, email, and household member receiving services.

Please detail any additional needs here.
YOUR SIGNATURE BELOW REPRESENTS AGREEMENT TO THE FOLLOWING:

Warning: §1001 of Title 18 of the United States Code makes it a criminal offense to make a willfully false statement or misrepresentation to a Department or agency of the United States as to any matter within its jurisdiction.

I certify that the information I have provided is complete and true to the best of my knowledge. I understand that omission of pertinent information and willful or serious misrepresentation in the application procedure can result in my ineligibility for participation in STEP’s Master Leasing Program.

I understand that in signing this application, I authorize STEP, Inc. to obtain verification of the above information for the processing and approval of my eligibility for STEP’s Master Leasing Program.

I have listed above the total current income received by every member of my household.

I have read the application packet and understand the materials provided explaining the eligibility criteria and objectives of the applicable programs.

The information provided in this application packet is complete and accurate to the best of my ability. I authorize STEP, Inc. to exchange, with other agencies and STEP programs, any information that is pertinent to the delivery of services requested. A photostatic copy of this authorization shall be considered valid.
Applicant/Owner/Tenant Name*
Applicant/Owner/Tenant*

Clear
Co-Applicant/Co-Owner/Co-Tenant Name
Co-Applicant/Co-Owner/Co-Tenant

Clear
After completing this form, you will be directed to STEP's General Registration.

Your application will not be considered complete and cannot be processed if you do not complete this additional form.
Should be Empty:

Master Leasing Program

Household Composition

Income Information

Family Information

Residence Information