Person will imminently lose Court order/eviction notice or primary nighttime residence Yes No NA other official notice to vacate from within 14 days and meets both landlord of the following circumstances, Eviction letter from and tenant/homeowner (if living with - No appropriate subsequent another, i.e. doubled up) housing options have been Letter from hotel/motel manager identified, and and cancelled checks to verify - Household lacks the financial costs covered by the participant resources and support Documentation of efforts to divert networks needed to obtain from homelessness (contact with immediate housing or remain HPP or ESG provider) in its existing housing. Letter from halfway house, jail, or state penitentiary Staff documentation of attempts to obtain third-party verification (required): Third-party verification is the HUD-preferred method of certifying homelessness or risk for homelessness for an individual who is applying for homeless assistance. Self-Declaration of Homelessness: Self-declaration is only permitted when third-party verification cannot be obtained. Due diligence by staff to obtain third-party verification must be described above. Participant Signature: ______________________________________ Date: ______________ Staff Signature: ___________________________________________ Date: ______________
Person will imminently lose primary nighttime residence within 14 days and meets both of the following circumstances, and - No appropriate subsequent housing options have been identified, and - Household lacks the financial resources and support networks needed to obtain immediate housing or remain in its existing housing. Court order/eviction notice or other official notice to vacate from landlord Eviction letter from tenant/homeowner (if living with another, i.e. doubled up) Letter from hotel/motel manager and cancelled checks to verify costs covered by the participant Documentation of efforts to divert from homelessness (contact with HPP or ESG provider) Letter from halfway house, jail, or state penitentiary Yes No NA Staff documentation of attempts to obtain third-party verification (required): Third-party verification is the HUD-preferred method of certifying homelessness or risk for homelessness for an individual who is applying for homeless assistance. Self-Declaration of Homelessness: Self-declaration is only permitted when third-party verification cannot be obtained. Due diligence by staff to obtain third-party verification must be described above. Participant Signature: ______________________________________ Date: ______________ Staff Signature: ___________________________________________ Date: ______________