Domestic Violence-Related Homelessness Verification Letter

Date:

To Whom It May Concern,

This letter is to verify that:

Name of applicant:

Date of birth:

Address:

Has experienced homelessness or housing instability as a result of domestic violence, dating violence, sexual assault, or stalking.

Brief description of situation (optional):

I am a (check one):

Victim service provider

Medical or clinical professional

Intake/staff of agency or housing provider

Other:

Name of verifying professional/agency:

Title/position:

Signature:

Date:

Contact phone/email:

This verification is provided to establish eligibility for housing and/or services. All information will be kept confidential as required by law.