HUD Homeless Certification
Applicant Information
Applicant Name
Date of Birth
Social Security Number
Current Address (if any)
Contact Number
Homeless Status
Type of Homeless Status
Literal Homeless (shelter, streets, car, etc.)
Fleeing Domestic Violence
Imminent Risk of Homelessness
Date Homelessness Started
Details of Living Situation
Location(s) Where Applicant Stayed
Location Name and Address
Type (Shelter, Street, etc.)
Dates
Certifying Agency Representative
Agency Name
Representative Name
Title
Phone
Email
Signature
Date
Notes/Comments