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Supportive Services for Veteran Families (SSVF) Program SELF-DECLARATION OF HOUSING STATUSSSVF Participant Name: ______________________________________________ FORMCHECKBOX Household without dependent children (complete one form for each adult in the household) FORMCHECKBOX Household with dependent children (complete one form for household)Number of persons in the household: _________ This is to certify the housing status of the above named individual or household, based on the following and other indicated information and the signed declaration by the applicant.Check only one: FORMCHECKBOX I [and my children] am/are currently residing in permanent housing. FORMCHECKBOX I [and my children] am/are homeless and scheduled to become a resident of permanent housing within 90 days pending the location or development of housing suitable for permanent housing. FORMCHECKBOX I [and my children] have exited permanent housing within the previous 90 days to seek other housing that is responsive to the my/our needs and preferences.I certify that the information above and any other information I have provided in applying for SSVF assistance is true, accurate and complete. SSVF Participant Signature: ____________________Date: ______________________SSVF Staff Certification I understand that third-party verification is the preferred method of certifying housing status for an individual who is applying for SSVF 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:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SSVF Staff Signature: _______________________Date: ______________________ ................
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