Request For Services

RCPH Program Referral Release Form

RCPH is a short-term program (0-6 months) that provides early intervention rental counseling to help renters in Lancaster County retain their housing. Budget and housing counseling are provided; we do not provide cash assistance, emergency housing, or Section 8.

To complete an application, either:


  • Colored fields indicate required information.

Applicant Information
Name *REQUIRED*
Address *REQUIRED*
City, State, ZIP *REQUIRED*
Email *REQUIRED*
Home phone
Work phone
Cell phone
DOB *REQUIRED*
# of Adults *REQUIRED*
# of Children *REQUIRED*
Have you used Tabor services in the past? *REQUIRED*
Support Systems
Emergency Contact Name *REQUIRED*
Phone *REQUIRED*
Referred by *REQUIRED*
Phone *REQUIRED*
Other Agency
Contact name
Phone
Other Agency
Contact name
Phone
Income Information
Do you have current income? *REQUIRED*
Source of income
If No, what means do you have to obtain income in the near future?
Gross income per month
$
Comments
Housing Information
Do you have a lease in your name? *REQUIRED*
Names on lease *REQUIRED*
Landlord's name *REQUIRED*
Address *REQUIRED*
Phone *REQUIRED*
Is your present landlord willing to work with you to maintain your housing? *REQUIRED*
Comments
Monthly rent *REQUIRED*
$
Arrears
$
Number of months past due *REQUIRED*
Has a notice to quit been issued? *REQUIRED*
Termination Date
Has landlord filed a possession? *REQUIRED*
Court Date
Lock out date
Comments
If you cannot stay in present housing what is your plan for alternative housing?
Orientation Sign-Up

Applicants must sign up and attend an RCPH Orientation. Please bring ID, proof of income and rental paperwork (lease/Notice to Quit) to orientation session.

Applicant will attend the scheduled orientation and landlord/tenant class on *REQUIRED*
1st & 3rd Fridays, 1pm at Ephrata Area Social Services; 2nd Fridays, 10am at Tabor
Authorization and Release

I authorize Tabor Community Services to discuss my information with landlords and other agencies, as necessary, for the processing of my RCPH application. I understand that I am not yet a client of Tabor's RCPH Program and will be notified of the application status after attending an orientation and assessment. I verify that the above information is true and accurate.

Online Signature *REQUIRED*
An electronic signature, made by checking a box below, is equivalent to a signature on paper.

When you click "Send Now", you will be brought to a confirmation page and receive a confirmation email letting you know that this application has been submitted successfully.