Fillable AFFIDAVIT OF HOMELESS STATUS FOR FEE EXEMPT CERTIFIED (Sacramento County, California)

Fill Online, Printable, Fillable, Blank AFFIDAVIT OF HOMELESS STATUS FOR FEE EXEMPT CERTIFIED (Sacramento County, California) Form

Use Fill to complete blank online SACRAMENTO COUNTY, CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

AFFIDAVIT OF HOMELESS STATUS FOR FEE EXEMPT CERTIFIED (Sacramento County, California)

On average this form takes 3 minutes to complete

The AFFIDAVIT OF HOMELESS STATUS FOR FEE EXEMPT CERTIFIED (Sacramento County, California) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 11 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Sacramento County, California forms online.

BROWSE SACRAMENTO COUNTY, CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
State of California – Health and Human Services Agency California Department of Public Health
AFFIDAVIT OF HOMELESS STATUS FOR FEE EXEMPT
CERTIFIED COPY OF BIRTH CERTIFICATE
2 of 2 Rev. 06/15
PLEASE READ THE INFORMATION SECTION BEFORE COMPLETING THIS AFFIDAVIT
Pursuant to Health and Safety Code Section 103577, each local registrar or county recorder shall, without a fee, issue a
certified record of live birth to any person who can verify his or her status as a homeless person or a homeless child or
youth. This affidavit must be used for the purpose of requesting a fee exempt certified copy of a Certificate of Live Birth.
SECTION I.
To be completed by the person making the request for the certified birth record (hereafter: “requestor”)
I, _________________________________ swear or affirm, to the best of my knowledge and belief,
Printed Name of Requestor
that on the date listed below in this section, I am:
____ a homeless person, or homeless child or youth;
OR,
____ a person lawfully entitled to request a certified record of live birth on behalf of the
following homeless child or youth _________________________________________,
Printed Name of Homeless Child or Youth
who is homeless, as defined by 42 U.S.C. Section 11301 et. seq.
Signature of Requestor ___________________________________ Date __________________
SECTION II.
To be completed by a “homeless services provider” (See authorized list on reverse side)
Entity Name of Homeless Services Provider Furnishing Verification of Homelessness:
_______________________________________________________________________________
Address: _______________________________________________________________________
Phone Number: ___________________________ E-mail: _______________________________
I, __________________________________ swear or affirm, to the best of my knowledge and belief
Printed Name of Agent for Provider
that on the date listed below in this section, ______________________________________________________________
Printed Name of Homeless Person or Homeless Child or Youth
is a homeless person or homeless child or youth, as defined by 42 U.S.C. Section 11301 et seq., and
that I meet the requirements of a “homeless services provider” as defined within California Health and
Safety Code Section 103577.
Signature of Agent for Provider ______________________________ Date __________________
Reset
Print
State of California – Health and Human Services Agency California Department of Public Health
AFFIDAVIT OF HOMELESS STATUS FOR FEE EXEMPT
CERTIFIED COPY OF BIRTH CERTIFICATE
1 of 2 Rev. 06/15
INFORMATION
A fee exempt copy of a birth record may be obtained from the local registrar or
county recorder office in the county where the registrant was born. A fee exempt
copy cannot be obtained from the State Registrar.
Each eligible person may only receive one fee exempt birth record, per application.
Requests for fee exempt copies are still subject to other requirements outlined in the
application for obtaining copies of birth records.
Applications for a certified copy of a birth record may be obtained by contacting the
vital records office in the county where the birth occurred.
Requirements for eligibility to receive a fee exempt copy of a birth certificate:
Requests may be made by a homeless person, child or youth who can verify status
as homeless.
Requests may be made by a homeless person, child, or youth on behalf of
themselves or by any person lawfully entitled to request a certified record of live birth
on behalf of a homeless person, child, or youth.
A “homeless person” and a “homeless child or youth” have the same meaning as
defined in 42 United States Code Section (U.S.C.) 11301 et seq.
A “homeless services provider,” as defined by statute, who has knowledge of a
person’s status as homeless, must provide verification through completion of the
affidavit.
The affidavit will not be considered complete unless signed by both the homeless
services provider and the person making the request for the birth record.
A “homeless services provider” includes:
1) A governmental or nonprofit agency receiving federal, state, or county or municipal
funding to provide services to a “homeless person” or “homeless child or youth,” or
that is otherwise sanctioned to provide those services by a local homeless
continuum of care organization.
2) An attorney licensed to practice law in this state.
3) A local educational agency liaison for homeless children and youth designated as
such pursuant to Section 11432(g)(1)(J)(ii) of Title 42 of the United States Code, or
a school social worker.
4) A human services provider or public social services provider funded by the State of
California to provide homeless children or youth services, health services, mental or
behavioral health services, substance use disorder services, or public assistance or
employment services.
5) A law enforcement officer designated as a liaison to the homeless population by a
local police department or sheriff’s department within the state.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

AFFIDAVIT OF HOMELESS STATUS FOR FEE EXEMPT CERTIFIED (Sacramento County, California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document