HOMELESS CERTIFICATION FORM
Last updated December 2018
Applicant Name and Unique Identifier: _________________________________________________________
Staff Member Name: __________________________________________
Household without dependent children (complete one form for each adult in the household)
Household with dependent children (complete one form for household)
Number of persons in the household: _________
This is to certify that the above named individual or household is currently either literally or imminently
homeless based on the check mark, other indicated information, and signature indicating their current
living situation. Check the appropriate type of documentation used to verify homelessness and attach it to
this worksheet.
CHRONIC HOMELESS CERTIFICATION
*Agency must select “Yes” if household meets the following criteria:
Individual or family is literally homeless and has third-party, intake worker, or household documentation of
the following:
Has been homeless for at least one year continuously or on at least four separate occasions in the last
three years, where the cumulative total of the four occasions is at least one year (Stays in institutions of 90
days or less will not constitute a break in homelessness, but such stays are included in the cumulative total)
in a place not meant for human habitation, a safe haven, or an emergency shelter; AND
Has an adult head of household (or a minor head of household if no adult is present in the household)
with a diagnosable substance use disorder, serious mental illness, developmental disability post-traumatic
stress disorder, cognitive impairments resulting from a brain injury, or chronic physical illness or disability,
including the co-occurrence of 2 or more of those conditions.
CHRONICALLY HOMELESS: Yes* No
GENERAL HOMELESS CERTIFICATION
Complete with information on the primary cause of homelessness
Homeless Status
Type of Eligible Documentation
Documentation/
Eligibility
LITERAL HOMELESSNESS (RAPID RE-HOUSING ELIGIBLE)
Persons living on the street or
sleeping in a place not designed for
or ordinarily used as a regular
sleeping accommodation
Signed and dated written certification
by person seeking services
Signed and dated written certification
by an outreach worker
Yes No
Persons living in a shelter designed
to provide temporary living
arrangements
- emergency shelter
- transitional housing
- hotel/motel paid for by a charitable
organization or government
program
HMIS shelter record
Written referral from previous shelter
staff
Written referral from charitable
organization or government program
Yes No
Persons exiting an institution where
they resided for 90 days or less and
resided in a place not meant for
HMIS shelter record
Written referral from previous shelter
Yes No
HOMELESS CERTIFICATION FORM
Last updated December 2018
human habitation immediately
before entering institution
staff
Written referral from institution
Persons fleeing domestic violence.
*Must meet one of the homeless
status categories listed above*
Written, signed and dated verification
from the participant
Written, signed and dated verification
from the domestic violence service
provider.
Yes No
IMMINENT RISK OF HOMELESSNESS (TARGETED PREVENTION ELIGIBLE)
Person will imminently lose primary
nighttime residence within 14 days
and meets both of the following
circumstances:
- No appropriate subsequent
housing options have been
identified; AND
- Household lacks the financial
resources and support networks
needed to obtain immediate housing
or remain in its existing housing
Documentation of diversion (notate in
case file)
Eviction letter from tenant/homeowner
(If living with another, i.e. doubled up)
Letter from hotel/motel manager and
cancelled checks to verify costs covered
by the participant
Court order/eviction notice
Yes No
Persons fleeing domestic violence
*Must also be imminently
homeless*
Written, signed and dated verification
from the participant
Written, signed and dated verification
from the domestic violence service
provider.
Yes No
Documentation of attempts to obtain third party verification (required): Third party verification is the
preferred method of certifying homelessness or risk for homelessness for an individual who is applying for
homeless assistance.
Self Declaration of Homelessness: Self declaration is only permitted when third party verification cannot be
obtained.
Participant Signature: _________________________________________ Date: ______________
Form Completed By: _________________________________________
Staff Signature: _____________________________________________ Date: ______________
