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The form defines eligibility categories based on the applicant’s housing situation at intake and outlines what documentation must be attached for each category, including written observation, written referrals, court or legal notices, discharge paperwork, and—rarely—self-declarations when third-party verification cannot be obtained. 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Determination and documentation of eligibility must be based on homeless status at intake; intake is the time the individual or family enters the project and begins receiving assistance under the grant program. This form excludes income eligibility requirements; please refer to the applicable program regulation to determine requirements. For projects funded to serve persons with disabilities, attach the Verification of Disability form. For projects funded to serve Chronically Homeless persons, attach the Verification of Chronic Homelessness form.  \nApplicant Name:   HMIS ID:    \nType of Assistance:  \n􀂅 Emergency Shelter (ES) 􀂅 Transitional Housing (TH)  \n􀂅 Permanent Supportive Housing (PSH) 􀂅 Supp. Services Only (SSO)  \n􀂅 Rental Assistance (RA) (incl. Prevention, Rapid Rehousing (RRH))  \n\n| Housing Status | Documentation Attached |\n| --- | --- |\n| Literally Homeless (Category 1)\u003Cbr>Individual or family who lacks a fixed, regular, and adequate nighttime residence |  |\n| Is sleeping in a place not designed for or ordinarily used as a regular sleeping accommodation ([incl. car](incl. car), park, abandoned building, bus/train station, airport)\u003Cbr>OR\u003Cbr>Is living in a publicly or privately operated shelter designated to provide temporary living arrangements (incl. congregate shelters, transitional housing, hotels/motels paid for by charitable orgs or federal/ state/local government programs)\u003Cbr>OR\u003Cbr>Is exiting an institution (Must have resided in an institution for 90 days or less AND Must have come from the streets or ES immediately before entering the institution) | 􀂅 Written observation by outreach worker of the conditions where the individual or family is living. HMIS record may be used (dates of stay/ services should be concurrent with application for assistance)\u003Cbr>OR\u003Cbr>􀂅 Written referral by another housing or service provider. HMIS record may be used (dates of stay/services should be concurrent with application for assistance). If unable to obtain written third-party documentation, may\u003Cbr>obtain oral* statement.\u003Cbr>OR\u003Cbr>􀂅 Certification on the Self-Declaration of Eligibility form signed and dated by applicant stating where (s)he is residing. Self-declaration of housing status should be used very rarely and only when written third party verification cannot be obtained (Exception: lack of third-party documentation must not prevent an individual or family from being immediately ad\u003Cbr>mitted to emergency shelter)\u003Cbr>AND\u003Cbr>􀂅 Intake worker must document due diligence** to obtain third-party verification. Intake worker may also document any assessments ofthe applicant’s housing status on the Documentation of Homelessness form\u003Cbr>􀂅 Discharge paperwork with the entry/exit dates or duration of stay in the\u003Cbr>institution\u003Cbr>OR\u003Cbr>􀂅 Written statement from institution official with the entry/exit dates or duration of stay in the institution If unable to obtain written third-party documentation, may obtain oral* statement.\u003Cbr>OR\u003Cbr>If evidence cannot be obtained from the institution, documentation must include:\u003Cbr>􀂅 A written record of the intake worker’s due diligence** in attempting to\u003Cbr>obtain discharge paperwork\u003Cbr>AND\u003Cbr>􀂅 Certification on the Self-Declaration of Eligibility form that the applicant has just exited an institution with the entry/exit dates or duration of\u003Cbr>stay\u003Cbr>AND\u003Cbr>􀂅 Stay on the streets or in an emergency shelter prior to entering the institution (acceptable forms of evidence described above) . HMIS record maybe used (dates of stay/services should be concurrent with entry into an in\u003Cbr>stitution) |\n\nPersons who meet the category 1 definition are eligible for the following types of assistance:  \nES, TH, PSH, SSO, RA (excluding prevention)  \n\n| Housing Status | Documentation Attached |\n| --- | --- |\n| Imminent Risk of Homelessness (Category 2)\u003Cbr>Individual or family who will imminently lose th","cbCaiehruxZR6PPY","https://ap.wps.com/l/cbCaiehruxZR6PPY","pdf",808282,"English","# Verification of Homelessness\n## Intake requirements and eligibility basis\n## Applicant information and assistance type\n## Housing status categories and required documentation","[{\"question\":\"What is the purpose of the Verification of Homelessness Intake Form?\",\"answer\":\"It records homelessness documentation for individuals and families seeking assistance, and ensures eligibility determination is based on homeless status at intake.\"},{\"question\":\"What documentation is generally required to verify Literally Homeless (Category 1)?\",\"answer\":\"Documentation must match the defined housing situation and may include written observation, written referral, discharge paperwork, written statements from institutions, and due diligence records; self-declaration is used only very rarely.\"},{\"question\":\"Does the form consider income eligibility requirements?\",\"answer\":\"No. It excludes income eligibility requirements and directs users to the applicable program regulation for those requirements.\"}]","Verification of Homelessness Intake Form | PDF",1789557974]