Adult Homeless Verification Form

Client/Consumer Name
Unity ID#
I certify that the Client/Consumer above lacks fixed, regular, and adequate nighttime residence as evidenced by one of the following and no appropriate subsequent housing options available and the household/individual lacks the financial resources and support networks needed to obtain immediate housing or remain in its existing housing. *Check all that apply, please provide address and description where applicable or specify NONE.
Location:
Location:
Location:
?
Copy of police report needed
Chronic Homelessness (Must meet all 3 conditions below and come from the street or emergency shelter)
Has a disabling condition of:
FOR USE BY SOCIAL SERVICE AGENCY/SHELTER/OUTREACH WORKER (PROVIDING VERIFICATION)
Name of Agency, Case Manager, and Title
Address
The above individual has been homeless since:
Phone #
Signature
Date
FOR USE BY AGENCY REQUESTING VERIFICATION
Name of Agency and Case Manager
Address
Phone #
Fax #
Siganture
Date