Applicant Information

First Name

Last Name

Phone

Social Security Number

Email

Current Address
Unit Number (Optional)

City

State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Co-Applicant Information (must be 18 years or older)

First Name

Last Name

Phone

Social Security Number

Current Landlord (or Name of person you are currently living with)

First Name

Last Name

Phone

Street Address
Unit Number(Optional)

City

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Why are you moving from your current address?

Have you added or removed anyone in your household since you applied?

Has the income changed for anyone in the household?

First Name

Last Name

Start Date

Income Type —Please choose an option—WorkingSS, SSD, SSI, SSPCash AssistanceChild Support, AlimonyUnemploymentOther

Gross(Before Tax) Amount

Frequency —Please choose an option—Per HourPer WeekBi-WeeklyMonthlyAnnualy

Hourly Rate

Number of Hours per Week

Add Another Income Change

Has the income changed for anyone in the household?

First Name

Last Name

Start Date

Income Type —Please choose an option—WorkingSS, SSD, SSI, SSPCash AssistanceChild Support, AlimonyUnemploymentOther

Gross(Before Tax) Amount

Frequency —Please choose an option—Per HourPer WeekBi-WeeklyMonthlyAnnualy

Hourly Rate

Number of Hours per Week

Cancel

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction. Your position on the waiting list may change depending on the updates of your application.

By checking this box you are affirming that the information provided is true and correct and you are proving consent to the Lycoming County Housing Authority to verify the information.