Self-Declaration of Housing Status

Applicant Name: ______________________________________________

Check one:

I am a household without dependent children (complete one form for each adult in the household)

I am a household with dependent children. Number of persons in the household: _________

This is to certify that the above-named individual or household is currently homeless based on the following:

CATEGORY 1

Check only one: I am an individual or family who lacks a fixed, regular, and adequate nighttime residence as

follows:

My primary nighttime residence is a public or private place not meant for human habitation.

I [and my children] are living in a publicly or privately operated shelter designated to provide temporary living

arrangements (including congregate shelters, transitional housing, and hotels/motels paid for by charitable

organizations or by federal, state, and local government programs).

I am exiting an institution where I have resided for 90 days or less and resided in an emergency shelter or place

not meant for human habitation immediately before entering that institution.

CATEGORY 2

I am an individual or family at imminent risk of losing my primary nighttime residence homelessness and have all

of the following circumstances:

My residence will be lost within 14 days of the date of this notice; and

No subsequent residence has been identified; and

I (and my children) lack the resources or support networks needed to secure permanent housing.

CATEGORY 3

I am an unaccompanied youth under 25 years of age, or a family with children and youth, who do not otherwise

qualify as homeless, but meet all of the following circumstances:

I am defined as homeless under another federal statute; and

I have not had a lease, ownership interest, or occupancy agreement in permanent housing during the 60 days

prior to this application for assistance; and

I have experienced persistent instability as measured by two moves or more during the preceding 60 days; and

I expect to continue in such status for an extended period of time due to special needs or barriers defined as

follows: __________________________________________________________________

CATEGORY 4

I am an individual or family that is:

• Fleeing, or attempting to flee, domestic violence; and

• Have no other residence; and

• Lack the resources or support networks to obtain other permanent housing.

I certify that the information above and any other information I have provided in applying for assistance is true,

accurate and complete.

Applicant Signature: _______________________________________ Date: ______________________

For official use only:

Staff Certification

I understand that third-party verification is the preferred method of documenting homeless status for an individual

or family who is applying for assistance. I understand self-declaration of housing status is allowed when third-party

documentation is not readily available.

Justification for reliance on Self-Certification Documentation:

________________________________________________________________________________________

Shelter Staff Signature: _______________________________________ Date: ______________________