SELF-DECLARATION OF HOUSING STATUS
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:
Approximate Date Homelessness Started:
This is to certify that the above named individual or household is currently homeless based on this executed self-
certification and other homeless certification information obtained and attached.
Authorized Signature:
Date:
Check only one:
I [and my children] am/are currently homeless and living on the street (i.e. a car, park, abandoned building, bus
station, airport, or camp ground).
I [and my children] am/are the victim(s) of domestic violence and am/are fleeing from abuse.
Approximate Date Homelessness Started:
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:
Staff Certification of Homelessness
I understand that third-party verification is the preferred method of certifying homelessness for an individual who is
applying for assistance. I understand self-declaration is only permitted when I have attempted to but cannot obtain
third party verification.
Documentation of attempt made for third-party verification:
Staff Signature:
Date:
