Pre-Application

Pre-Application

This pre-application is for all Family Promise HCR Program. Please fill out all required fields or the application will be denied
PLEASE READ:

MOVE UP (rental assistance) PROGRAM IS CLOSED. FUNDING AS BEEN DEPLETED FOR THE MONTH OF DECEMBER.

Wheels UP (transportation assistance) Program is closed till January. Funds have been depleted for December.

Only 1 application per household allowed for all Family Promise HCR Programs.

If there is a required question that does not apply to you, please type N/A
Information for Move UP Program - There is no guarantee approval of funding
1. Rental assistance for ONE month in back rent.
2. 1st month/security for a new lease. CLIENT MUST HAVE ALREADY BEEN APPROVED FOR AN APARTMENT BEFORE APPLYING.
3. Cumberland and Dauphin County residents only.
4. Must have at least one child under the age of 18 living in the household.
5. Must be employed or have stable income that is able to sustain rent at the time of application.
6. Will be required to complete 3 FDIC Money Smart Lessons and Homework before approved for funding.
7. Client must be able to provide landlords name, address, and phone number.
8. Funding must be the FINAL amount to provided to resolve the situation.
9. All funding goes directly to the landlord to resolve the issue.
10. Partial repayment of the loan is required to be paid back over 12 months.
11. Applications are processed in the order required materials are turned in.
12. *Does not cover hotel room rentals*
Information about Wheels UP Program - There is no guarantee approval of funding
1. Funding assistance to help cover the costs associated with permanent transportation.
2. Cumberland, Perry and Dauphin County residents only.
3. Have Pennsylvania ID or DL at time of application.
4. Must have at least one child under the age of 18 living in the household.
5. Must be employed or have stable income that is able to sustain transportation.
6. Will be required to complete 2 FDIC Money Smart Lessons and Homework before approved for funding.
7. Funding must be the FINAL amount to be provided to resolve the matter.
8. Partial repayment of the loan is required to be paid back over 12 months.
9. Application are processed in the order required materials are turned in.
10. Case manager referral is required.
Basic requirments for the Family Promise Shelter Program -

1. Family must have at least one child under the age of 18 living in the household.

2. Must be at least 30 days from active DV situation. Case by case basis for domestic violence situations over 30 days.

3. Must be at 30 days clean from drugs or alcohol. If you need resources, please let us know.

4. Currently reside in South Central Pennsylvania. If you are outside of South Central Pennsylvania, please call 2-1-1 for further assistance.
Do you live in South Central Pennsylvania?*

YesNo
County of residence*

Cumberland CountyPerry CountyDauphin CountyOther
Have you been clean from any substance for at least the last 30 days?*

YesNoOther
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Are you currently fleeing an active domestic abuse situation?*

YesNo
Have you experienced domestic violence in the past?

YesNo
If you feel comfortable, please explain your domestic abuse situation. Please include date of last encounter, if past experience. *
Are you the head of household?*

YesNo
Family Composition*

Two Parent FamilyFemale Single ParentMale Single ParentOther Composition
Race*
Gender

MaleFemale
Did you read the PLEASE READ section at the top if this form? If you did not, please go back to read this section as it has important information about our programs.*

Yes, I did read this sectionNo
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Greatest area of need. *One application per household**

Shelter - Clients rotate shelter each weekJob placement assistance - Road to SuccessHeads UP Program - Mental health counseling related to experiencing homelessness *Cumberland, Perry, and Dauphin County residents only*Wheels UP Program (Partial Repayment required) CASE MANAGER REQUIREDMove UP Program (Partial Repayment required)
Please provide an explanation of your need. *
Do you understand that if you apply for any UP Program that is listed as CLOSED, you will be automatically denied for that service?*

YesNo
Length of stay at this address if behind on rent*
If you are applying for the Move UP Program, what is your rent per month?*
Landlord information - Must provide landlord name, address, and phone number *
What your total monthly income? *
Do you have current employment? If yes, please provide employer and length of employment. *
Is your current residence either public or section 8 housing?*

YesNoNot housed
Who is filling out this pre-application?

SelfCaseworkerOther
If caseworker or other, please state why
Email*
example@example.com
Verify Email *
example@example.com
Phone Number*
Please enter a valid phone number.
Please respond with your current family situation.*

I have at least 50/50 custody of my child(ren)I am pregnant or my partner is pregnantI do not have custody of my child(ren)My children are over the age of 18Due to my living situation, my child(ren) are not living with me. DO have legal custody.Other
Describe your current family situation if you selected OTHER. *
When did you first become homeless? *

MonthDayYear
Date
Reason for homelessness? *
What are your housing goals?
Referring agency (required for Wheels UP and Heads UP Programs) *
Referring case manager's name, phone, and email (required for Wheels UP Program and Heads UP Programs) *
Please list any providers that may have helped cover funding for housing or transportation*
For Move UP and Wheels UP Clients - Do you understand that you must provide certain required documents? (IE: lease, eviction papers, bill of sale, over due bills, DL)

YesNoI have no documentation
# of individuals OVER the age of 18 *This includes head of household**
# of children UNDER the age of 18 *
Family Size *
Please list all family members in the household's full name and date of birth. *including yourself* *
Have you been clean from substances in the last 30 days?*

YesNoI have my medical marijuana card
Form of valid ID*

Drivers LicenseID CardNone
DL/ID Number
Do you have a vehicle? *
Are you pregnant?

YesNo
If so, when are you due?
Are you disabled? If so, please describe.
History of chemical dependency?
Are you currently in school? If so, what grade?
I affirm that the information in this form is true and accurate according to my knowledge.

First NameLast Name
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