Rural Area Homelessness Verification Form
Applicant Information
Full Name
Date of Birth
Contact Number
Current Location/Address
Homelessness Verification
How long has the applicant been experiencing homelessness?
Primary reason for homelessness
Current living situation (describe where applicant currently stays)
Is the applicant located in a rural area?
Yes
No
Verification Agent
Verifier Name
Organization
Phone Number
Date of Verification
Signature