Date of interaction Brief description of interaction Where the applicant was living at that time (be specific) Ex 1: May 9, 2016 (Name of applicant) came into (Name of applicant) was the day shelter to get help sleeping in his car obtaining an ID Ex 2: June 2, 2016 (Name of applicant) came in to (Name of applicant) was get a meal and talked with staff sleeping in a park for a few minutes. __________________________________________________ Name of staff person who obtained the verbal verification ___________________________________________________ ________________ Signature Date __________________________________________ Title Certification of Homelessness from a Community Member form on third party agency letterhead if available) I have physically observed _________________________________ (name of applicant) living in a place not meant for human habitation on the dates listed below. I know or am familiar with ____________________________________ (name of applicant) because________________________ _____________________________________________________________________________________
Date of interaction Brief description of interaction Where the applicant was living at that time (be specific) Ex 1: May 9, 2016 (Name of applicant) came into the day shelter to get help obtaining an ID (Name of applicant) was sleeping in his car Ex 2: June 2, 2016 (Name of applicant) came in to get a meal and talked with staff for a few minutes. (Name of applicant) was sleeping in a park __________________________________________________ Name of staff person who obtained the verbal verification ___________________________________________________ ________________ Signature Date __________________________________________ Title Certification of Homelessness from a Community Member form on third party agency letterhead if available) I have physically observed _________________________________ (name of applicant) living in a place not meant for human habitation on the dates listed below. I know or am familiar with ____________________________________ (name of applicant) because________________________ _____________________________________________________________________________________
NM%20Chronic%20Homelessness%20Documentation%20Packet%20Updated%20Final%20June%202016.docx