HomeMy WebLinkAboutverification-of-homelessness-self-certification(Revised 10/25/19) P a g e | 7
*https://files.hudexchange.info/resources/documents/Defining-Chronically-Homeless-Final-Rule.pdf
Homelessness Self Certification Statement
Instructions: This form may be used when an applicant lacked connections with service
providers to complete a third-party verification of homelessness during a time period for which
homelessness must be verified. Service providers must document all attempts to obtain third
party verification for each self-certification (see below).
Applicant Name: ___________________________ Date of Birth: ____________ Phone or E-mail: ____________________________
I certify that I have been homeless during the following periods of time and in the following locations.
Location (address, name of public
space, street name, landmark, etc.):
Description of living conditions (sleeping in a car, in a
tent, in the open, etc.):
Start date: End date:
What else would you like to share about your homeless status during the period of time referenced above (optional)?
For example, “I cannot remember the name of the place where I was living during the fall of 2018 but I believe it was an
emergency shelter. I have problems with my memory from that time due to an illness.”
_______________________________________
________________________________
I certify that the above information is correct.
Signature of Client: Date of Signature:
Staff Section: DO NOT SKIP THIS STEP
Please document all attempts to obtain 3rd party verification for the period of homelessness documented above.
1) ___________________________________________________________________________________________
2) ___________________________________________________________________________________________
3) ___________________________________________________________________________________________
I reviewed the above statement with the applicant and certify that the attempts to obtain third-party verification are
accurate.
Name of Staff (Print): ________________________________________________________________________________
Staff Member Organization and Title: ____________________________________ Staff Phone Number: ____________
Signature of Staff: Date of Signature: ________________________