ESG Self-Certification of Homeless Status Form

SELF-CERTIFICATION OF HOMELESS STATUS
Participant Name: First* Last * Date: Date

This form is to certify that the household meets HUD's definition of homeless and that the intake worker was unable to obtain appropriate documentation verifying the participant's homeless status.
Check one of the following:
Number of persons in the household: number*
Participant check only one:
SELF-CERTIFICATION OF HOMELESS STATUS
Participant Signature: Signature* Date: Date*
DUE DILIGENCE: Describe intake worker's efforts to obtain third party certification:
Intake Staff/Outreach Worker Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: