Supportive Housing Program Application

  • Supportive Housing Program

    Application

  • Applicant must complete SHP Application, 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.

  • What Supportive Housing Program (SHP) level are you applying for?*
  • Tier II Referral Partner:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Household Composition

  • Are you the head of household?
    • Household Member #1 (Self) 
    • Birthdate*
       - -
    • Gender
    • Ethnicity (optional)
    • Are you the Head of Household?*
    • Household Member #2 
    • Birthdate*
       - -
    • Household Member #3 
    • Birthdate*
       - -
    • Household Member #4 
    • Birthdate*
       - -
    • Household Member #5 
    • Birthdate*
       - -
    • Household Member #6 
    • Birthdate*
       - -
    • Household Member #7 
    • Birthdate*
       - -
    • Household Member #8 
    • Birthdate*
       - -
    •  
    • Does a household member have a permanent physical, mental, or emotional disability?*
    • Does this disability limit access to and use of the dwelling unit?*

    • The disability will require verification by a certified/licensed professional and/or by other governmental source. (Paperwork for verification of disability will be sent you by our office).

    • Are there any children six years of age and under in the household?
    • Were the children ever tested for lead poisoning?
    • Do any of the children have elevated blood levels?

    • Income Information

    • HUD defines income as money or nonmonetary sources which go to the family or are provided on behalf of the family, head or spouse or to any other family member, or that is anticipated to be received from a source outside the family during the 12-month period following this application.

      Please list each person in the household who is receiving any source of income. Please provide a copy of each form of income.

      Sources of Income include: Net wages from employment or self-employment, income after business deductions, welfare/cash assistance, Social Security, SSI, unemployment, workers’ compensation, strike benefits, VA benefits, alimony, pension and annuity payments, training allowances and income from rent, estate, royalties, dividends and interest, and child support.

    • Name #1 
    • Payment frequency:*
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    • Name #2 
    • Payment frequency:
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    • Name #3 
    • Payment frequency:
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    • Name #4 
    • Payment frequency:
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    •  

  • Residence Information

  • Are you currently homeless?*
  • Are you registered with 211/Coordinated Intake?*
  • Type of dwelling:
  • How long have you lived at your current address?*
  • Do you receive subsidized, Section 8, or HUD housing assistance?*
  • Are you behind on your rent/mortgage?*
  • Do you owe back taxes?*
  • Do you currently have an eviction/foreclosure notice?*
  • Do you also own the land on which the manufactured/mobile home sits?
  • Do you currently have a shutoff notice for any of the following utility services? Check all that apply.*
  • Water service shutoff date:*
     - -
  • Gas service shutoff date:*
     - -
  • Electric service shutoff date:*
     - -
  • Regarding your current residence, which of the following documents do you possess?*
  • Have you lived within Lycoming County for a year or longer?*
  • Was your residence constructed or manufactured prior to 1978?*
  • Do you currently have (check all that apply):*
  • Format: (000) 000-0000.

  • 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 Supportive Housing 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 Supportive Housing 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.

     

  • Clear
  • Clear

  • After completing this form, you will be directed to STEP's General Registration. You must also complete this form as part of applying to the Supportive Housing Program!

  • Should be Empty: