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    Sample Homeless Certification

    Uploaded by

    Mr Frelot
    This document contains a sample certification form for homeless service providers to verify that applicants for an Emergency Housing Voucher meet the eligibility criteria of being currently homeless or at risk of homelessness. The form collects information about the applicant's current living situation by having the certifying agency check one of three options - that the applicant is living in a place not meant for habitation, an emergency shelter, or is recently homeless. The certifying agency must be recognized by the local Continuum of Care and an authorized representative must sign and date the form.

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    Sample Homeless Certification

    Uploaded by

    Mr Frelot
    139 views2 pages
    This document contains a sample certification form for homeless service providers to verify that applicants for an Emergency Housing Voucher meet the eligibility criteria of being currently homeless or at risk of homelessness. The form collects information about the applicant's current living situation by having the certifying agency check one of three options - that the applicant is living in a place not meant for habitation, an emergency shelter, or is recently homeless. The certifying agency must be recognized by the local Continuum of Care and an authorized representative must sign and date the form.

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    This document contains a sample certification form for homeless service providers to verify that applicants for an Emergency Housing Voucher meet the eligibility criteria of being currently homeless or at risk of homelessness. The form collects information about the applicant's current living situation by having the certifying agency check one of three options - that the applicant is living in a place not meant for habitation, an emergency shelter, or is recently homeless. The certifying agency must be recognized by the local Continuum of Care and an authorized representative must sign and date the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    139 views2 pages

    Sample Homeless Certification

    Uploaded by

    Mr Frelot
    This document contains a sample certification form for homeless service providers to verify that applicants for an Emergency Housing Voucher meet the eligibility criteria of being currently homeless or at risk of homelessness. The form collects information about the applicant's current living situation by having the certifying agency check one of three options - that the applicant is living in a place not meant for habitation, an emergency shelter, or is recently homeless. The certifying agency must be recognized by the local Continuum of Care and an authorized representative must sign and date the form.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    Attachment 3 - Example of a Homeless Provider’s Certification

    Emergency Housing Voucher (EHV)

    HOMELESS CERTIFICATION

    EHV Applicant 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 meets the following criteria based on
    the check mark, other indicated information, and signature indicating their current living situation-
    Check only one box and complete only that section

    Living Situation: place not meant for human habitation (e.g., cars, parks, abandoned buildings,
    streets/sidewalks)

    The person(s) named above is/are currently living in (or, if currently in hospital or other institution,
    was living in immediately prior to hospital/institution admission) a public or private place not designed
    for, or ordinarily used as a regular sleeping accommodation for human beings, including a car, park,
    abandoned building, bus station, airport, or camp ground.

    Description of current living situation:


    _____________________________________________________________________________________
    _____________________________________________________________________________________
    ______________________________________________

    Homeless Street Outreach Program


    Name:_________________________________________________________________________

    This certifying agency must be recognized by the local Continuum of Care (CoC) as an agency that has a
    program designed to serve persons living on the street or other places not meant for human habitation.
    Examples may be street outreach workers, day shelters, soup kitchens, Health Care for the Homeless
    sites, etc.

    Authorized Agency Representative Signature: _________________________________________


    Date: ______________________

    5
    Living Situation: Emergency Shelter

    The person(s) named above is/are currently living in (or, if currently in hospital or other institution,
    was living in immediately prior to hospital/institution admission) a supervised publicly or privately
    operated shelter as follows:

    Emergency Shelter Program Name:


    _____________________________________________________________

    This emergency shelter must appear on the CoC’s Housing Inventory Chart submitted as part of the most
    recent CoC Homeless Assistance application to HUD or otherwise be recognized by the CoC as part of the
    CoC inventory (e.g., newly established Emergency Shelter).

    Authorized Agency Representative Signature: _________________________________________


    Date: ______________________

    Living Situation: Recently Homeless

    The person(s) named above is/are currently receiving financial and supportive services for persons who are
    homeless. Loss of such assistance would result in a return to homelessness (ex. Households in Rapid Rehousing
    Programs, residents of Permanent Supportive Housing Programs participating in Moving On, etc.)
    Authorized Agency Representative Signature:
    ____________________________________________________________

    This referring agency must appear on the CoC’s Housing Inventory Chart submitted as part of the most
    recent CoC Homeless Assistance application to HUD or otherwise be recognized by the CoC as part of the
    CoC inventory.

    Immediately prior to entering the household’s current living situation, the person(s) named above
    was/were residing in:

    emergency shelter OR a place unfit for human habitation

    Authorized Agency Representative Signature: _________________________________________


    Date: ______________________

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