Emergency Shelter Homelessness Verification
Client Information
Client Name
Date of Birth
Last Known Address
Contact Information
Emergency Shelter Stay Details
Name of Shelter
Shelter Address
Stay Start Date
Stay End Date
Verification Statement
This is to verify that the above-named individual resided at our emergency shelter during the dates indicated above and met the definition of homelessness at that time.
Shelter Staff Certification
Staff Name
Staff Title
Shelter/Agency Name
Signature
Date