Unaccompanied Minor Homelessness Certification
Minor's Information
Name of Student:
Date of Birth:
School Name:
Grade Level:
Certification of Homeless Status
Current Living Situation (brief description):
Duration of Homelessness:
Is the student unaccompanied? (not in the physical custody of a parent or guardian):
Certifying Authority
Name of Certifying Official:
Title/Position:
Organization/Agency:
Contact Information:
Signature
Signature:
Date: