Homelessness Certification Form

HOMELESSNESS CERTIFICATION FORM

RECITALS

WHEREAS, Client Name: seeks official certification of homelessness status for eligibility determination and access to housing and supportive services; and

WHEREAS, Certifying Agency/Provider: is authorized to assess documentation and certify homelessness status in accordance with applicable program rules and this certification procedure; and

WHEREAS, the parties wish to record the facts, evidence, and terms under which certification is granted for program eligibility and recordkeeping purposes.

APPLICANT INFORMATION

HOUSEHOLD & HOMELESS HISTORY

Household Size (total persons):

Date homelessness began or most recent onset:

EVIDENCE & SUPPORTING DOCUMENTATION

Check all documentary evidence provided or relied upon for this certification:

SCOPE OF WORK

Describe the assessment actions, documentation review, and certification outcome to be performed by the Certifying Agency/Provider for this applicant:

PAYMENT TERMS (IF APPLICABLE)

Processing Fee Amount:

Payment Schedule / Due Date:

Late Fee / Penalty:

Note: If no fee applies, enter "No fee." Payment obligations, if any, are limited to the amounts and schedule set forth above and are non-refundable unless otherwise stated in writing by Certifying Agency.

TERM AND TERMINATION

Certification Effective Date:

Certification Expiration Date:

Termination / Revocation: This certification may be revoked or terminated by the Certifying Agency upon material misrepresentation, discovery of contrary evidence, or at the request of the Applicant. Notice of termination shall be provided in writing with a notice period of days.

CONFIDENTIALITY

All personal information, documentation, and records provided in connection with this certification shall be maintained in accordance with applicable privacy laws and agency recordkeeping policies. The Certifying Agency shall limit disclosure of applicant information to staff and authorized entities with a legitimate need to know for eligibility determination and service delivery, except as required by law. Applicant consents to necessary disclosures for verification and administration of benefits.

Applicant acknowledges that false statements or concealment of material facts may result in denial, revocation, or recovery of benefits and may subject the applicant to civil or criminal penalties.

GOVERNING LAW; ENTIRE AGREEMENT

This certification and any determinations made hereunder shall be governed by the laws of the state in which the Certifying Agency is located, without regard to conflict of law principles. This document constitutes the entire agreement between the Applicant and Certifying Agency with respect to the subject matter herein and supersedes all prior oral or written communications on this matter.

CERTIFICATION STATEMENT

I certify, under penalty of perjury, that the information provided on this form and any supporting documentation is true and correct to the best of my knowledge. I understand that this certification is provided for the purpose of establishing homelessness status for program eligibility and that knowingly making a false statement may be punishable by law.

ADDITIONAL AGENCY FINDINGS (TO BE COMPLETED BY CERTIFYING AGENCY)

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