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Homeless Verification FormDirections:This Homeless Verification Form is meant to be used to determine a household’s current housing/ homeless status based on HUD definitions. This form must be signed by an outreach worker, shelter staff member or staff from a service agency who is able to verify the applicant’s homeless status.Date Form Completed: _______________________________Applicant InformationName: ________________ Date of Birth: ____/____/______Verifying Agency InformationName of staff providing verification : ____________________________________ Phone: _____ - _____ - ________Agency: _________________________________________ Address: ________________________________________Statement and SignatureTo the best of my knowledge, the following is an accurate description of the client’s current housing situation._______________________________________________ ____________ Agency Staff Signature DateDirections:Please complete the questions on the Homeless Status Worksheet with a client following the instructions. The box immediately below is “For Office Use Only” and is to be filled out following completion of the Worksheet. Please reference the “Homeless Verification Documentation Guidance” to determine what documentation the household must collect to provide proof of the homeless status entered below. If documentation cannot be obtained, or contradicts the information on the Homeless Status Worksheet, please revise or complete a new Worksheet and Verification Form as necessary. BOX 1: FOR STAFF USE ONLYComplete this section after completing the following pages.Homeless StatusChronically Homeless? Category 1: Literally Homeless Category 2: Imminent Risk of Homelessness Category 3: Homeless Under Other Federal Statutes (N/A) Category 4: Fleeing/ Attempting to Flee Domestic Violence At Risk of Homelessness Stably Housed Yes NoRequired Verification Documentation Required homeless status verification documentation attached. Disability Verification attached (where applicable).Homeless Status Worksheet(Must be attached to Homeless Verification Form)START HEREDescription of Housing StatusDate of Entry into Current Residence: ____/____/______Applicant’s Current Residence: (Check ONLY ONE of the 19 options below and follow the instructions)Emergency Shelter Hotel or motel paid for by charity or government entity 407733515875Place not meant for habitation Safe Haven Applicant is Literally Homeless Fill in result in Box 1 on Homeless Verification Form andComplete Box A:Chronically Homeless Questions40798759525000Transitional housing for homeless persons Applicant is Literally HomelessFill in result in Box 1 on Homeless Verification Form andComplete Box B:Transitional QuestionsHospital Non–Psychiatric 407987516700500Jail, prison, juvenile detention facility Psychiatric hospital or other psych facility Substance abuse treatment or detox center Complete Box C:Institution QuestionsFoster care home/ foster care group home Hotel or motel paid for by yourself/ family member/ friend Owned by client, no housing subsidy Owned by client, with housing subsidy 407987532194500Permanent housing for formerly homeless persons(such as SHP, S+C)Rental by client, no housing subsidy Rental by client, with VASH housing subsidy Rental by client, with other (non-VASH) housing subsidy Staying or living in a family member's room, apartment or house Staying or living in a friend's room, apartment or house Complete Box D:At Risk for Homelessness QuestionsBox A: Chronically Homeless QuestionsA1. On what date did the applicant last live in an apartment, house or another place where people usually live? ____/____/______A2. Length of current episode of homelessness (at time of this assessment): _________ DaysA3. How many different occasions did the applicant live in a place where someone is not meant to live, in a shelter, in transitional housing and/or a hotel/motel paid for by a charity or government agency during the past 3 years? __________If the answer to A3. above is greater than one (1) please indicate the dates of previous homeless episodes within the last three years below:___/____/_____ to ____/____/_____ 2. ___/____/_____ to ____/____/_____3. ___/____/_____ to ____/____/_____ 4. ___/____/_____ to ____/____/_____A4. Has any member of the household been diagnosed with one or more of the following conditions: Substance Use, Disorder, Cognitive Impairments from a Brain Injury, Serious Mental Illness, Chronic Physical Illness or Disability, Development Disability, HIV/AIDS or Post-Traumatic Stress Disorder? Yes NoIf part A2. is 365 days (1 year) or more OR part A3. is 4 or more times, AND the answer to A4. above is “Yes” the applicant is Chronically Homeless.) Return to the Homeless Verification Form and fill in results in Box 1. Collect and attach documentation as required.Box B: Transitional QuestionB1. Did the applicant live in a place where someone is not meant to live or a shelter right before entering transitional housing? Yes NoYou are finished. Collect and attach documentation as required.Box C: Institution QuestionsC1. Was the applicant in a place not meant for human habitation or an Emergency shelter before the institution? Yes No If yes, continue to C2. If no, skip to Box E: At Risk for HomelessnessC2. Date of Exit/ Discharge from Institution: ____/____/______ (continue to C3.) C3. Calculated days in Institution at discharge: ___________If C3. is 90 days or less applicant is Literally Homeless. Fill in result in Box 1 on Homeless Verification Form and complete Box A: Chronically Homeless Questions above. If C3. is more than 90 Days continue to Box E: At Risk for Homelessness below.Box D: Homeless (Imminent Risk) QuestionsD1. Will the applicant have to leave in two weeks? Yes No If yes, continue to D2. If no, skip to Box E: At Risk for Homelessness below.D2. Has the applicant identified another place to live? Yes No If no, continue to D3. If yes, skip to Box E: At Risk for Homelessness below.D3. Does the applicant have resources or other support networks available to you to obtain other permanent housing? Yes No If yes, continue to Box F. Domestic Violence Questions. If no, applicant is Homeless: Imminent Risk. You are finished, fill in result in Box 1 on Homeless Verification Form.Box E. At Risk for Homelessness QuestionsE1. Does the applicant have other resources or support networks to prevent you from becoming literally homeless? Yes No If yes, applicant must complete Box F: Domestic Violence Questions below. If no, continue to E2. and E3.E2. Check all that apply: Has moved 2 or more times due to economic reasons in 60 days prior to this application Is living in the home of another due to economic hardship Has been notified in writing that their right to occupy their current housing or living situation will be terminated within 21 days from filling out this application Lives in a hotel/motel not paid for by charitable organizations, or federal/state/ local government entities Lives in a single-room occupancy or efficiency apartment unit in which there reside more than two persons, or lives in a larger housing unit in which there reside more than 1.5 people per room. Exiting publicly funded institution or system of careE3. Family Income as a percentage of the AMI: ____________________________If any in E2. are checked, and the family income is 30% of the AMI (Area Median Income) or less then the applicant is At Risk for Homelessness; You are finished; fill in results in Box 1 on Homeless Verification Form. If none in E2.are checked, OR family income is above 30% of the AMI then the applicant must complete Box F. Domestic Violence Questions below. Box F. Domestic Violence Questions***Only complete this box if directed here by instructions***F1. Is the applicant fleeing or attempting to flee domestic violence, dating violence, sexual assault, stalking, or other dangerous or life threatening situation related to violence against themselves or a member of their household at their primary nighttime residence? Yes No If yes, continue to F2. If no, applicant is Stably Housed. You are finished. Fill in results in Box 1 on Homeless Verification Form.F2. Does the applicant have another residence: Yes No If no, continue to F3. If yes, applicant is Stably Housed. You are finished. Fill in results in Box 1 on Homeless Verification Form.F3. Does the applicant have resources or support networks (family, friends, faith-based or other social networks) to obtain other permanent housing? Yes No If yes, applicant is Stably Housed. You are finished. Fill in results in Box 1 on Homeless Verification Form. If no, applicant is Homeless Due to Domestic Violence. You are finished. Fill in results in Box 1 on Homeless Verification Form. ................
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