Revised, June Home
Supportive Services for Veteran Families (SSVF) ProgramLITERALLY HOMELESS SELF-CERTIFICATION (Note: this form is used only for Rapid Re-housing i.e. SSVF categories 2 and 3) SSVF Applicant Name:Instructions: Complete this self-certification if third party documentation (i.e., written or oral verification) cannot be obtained from an appropriate third party. SSVF applicants may self-certify their current “literally homeless” status per one of the categories below and as defined in the SSVF Program Guide. SSVF staff should review this form with applicants and assist in completing, as needed. Applicants must sign and date this form.I certify that (check only one): FORMCHECKBOX I (we) am living in a car, park, abandoned building, bus/train station, airport, camping ground, or other place not designed for or ordinarily used as a regular sleeping accommodation, or am fleeing or attempting to flee a domestic violence situation.Description of Where You Are Staying: FORMCHECKBOX I (we) am staying in an emergency shelter OR a transitional housing program for people who are homeless OR a hotel or motel that is paid for by a charity or government program. Shelter, Transitional Housing or Hotel/Motel Name:Location:If Hotel/Motel: Name of Charity/Program Paying for Stay: FORMCHECKBOX I am exiting an institution where I have been staying for 90 days or less AND I stayed in an emergency shelter OR a place not designed for or ordinarily used as a regular sleeping accommodation immediately prior to entering that institution. Name of Institution:Location:Date of Admission:Description of Unsheltered Location:Shelter Name:Location:SSVF Applicant Signature: ______________________________________ Date: ____________ ................
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