19CHOME 1/11/2019
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
Section A1, Student
:
Student Name: ___________________________________________ HCC ID: _______________
At any time on or after July 1, 2018, did your high school representative determine that you were an
unaccompanied youth who was homeless? (High School Guidance Counselor or Dana Pentoney is
the Washington County Public School McKinney-Vento Homeless Youth Liaison)
Yes
No
At any time on or after July 1, 2018, did the director of an emergency shelter or transitional housing
program funded by the U.S. Department of Housing and Urban Development determine that you were
an unaccompanied youth who was homeless?
Yes
No
At any time on or after July 1, 2018, did the director of a runaway or homeless youth basic center of
transitional living program determine that you were an unaccompanied youth who was homeless or
were self-supporting and at risk of being homeless?
Yes
No
For a list of transitional housing and homeless shelters, visit: www.dhr.state.md.us/transit/
If you answered yes to any of the above questions, skip section A2, and sign the form below. Take
Section B on the next page to be filled out by the School District Liaison or Shelter Director and submit
both pages to the Financial Aid office.
If you answered no to all of the above questions, continue on to section A2 and skip section B, also,
please be sure to sign the form below.
Section A2:
Check the correct answer to the following questions. More than one of these situations may apply to you.
Yes No
Do you stay in the same place every night?
Do you move around a lot?
Do you have keys to the place where you live?
Do you have the legal right to be in the home where you sleep?
Are you or your parent(s) homeless because of an eviction or the inability to pay rent or mortgage?
Are you homeless because of a natural disaster that destroyed your previous home? If yes, when did the
disaster occur? Date ____________________
Did you or your parent(s) become homeless due to unemployment? If yes, when did you or your parent(s)
become unemployed? Date _____________________
Did you or your parent(s) become homeless when you lost public benefits (Social Security, TANF, etc.)?
If yes, what date did you last receive these benefits?
If you answered yes to any of the questions in Section A2, please sign this form and contact the
Financial Aid Office to make an appointment with the Student Financial Aid Administrator.
Student Financial Aid Office
11400 Robinwood Drive
Hagerstown, MD 21742
finaid@hagerstowncc.edu
FAX: 301-791-9165
2019-2020
Homelessness Form
Student Financial Aid Office
11400 Robinwood Drive
Hagerstown, MD 21742
Phone: 240-500-2473
finaid@hagerstowncc.edu
FAX: 301-791-9165
Student Signature: ___________________________________ Date:__________________
