Fillable Documentation of Homelessness Affidavit

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Documentation of Homelessness Affidavit

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The Documentation of Homelessness Affidavit form is 2 pages long and contains:

  • 2 signatures
  • 3 check-boxes
  • 25 other fields

Country of origin: OTHERS
File type: PDF

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Documentation of Homelessness
Affidavit
Applicant Name: _____________________________________________ Date:___________________
Please check the statement that applies to your household below:
Household without dependent children
Household with dependent children
Number of persons in the household:______________
Please check the statement that applies to your household below:
I am currently homeless and living on the street (i.e. a car, park, abandoned building, bus station,
airport, camp ground or in the woods in the area of ________________________.
I was living unsheltered starting __________________ ended _______________ in the City of
____________________ and State of _____________________. Reason for living unsheltered
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I and my spouse/other am/are currently homeless and living on the street (i.e. a car, park, abandoned
building, bus station, airport, camp ground or in the woods in the area of __________________________.
I and my spouse/other (and my child(ren) are currently homeless and living on the street (i.e. a car,
park, abandoned building, bus station, airport, camp ground or in the wood in the area of
____________________________.
I (and my child(ren) am/are the victim(s) of domestic violence and am/are fleeing from abuse. I
am currently being court evicted from my housing at the address of ___________________________
______________________ and must leave this residence with the next ______days.
I and my spouse/other am/are currently being court evicted from our housing at the address of
_____________________________________________________ and must leave this residence within the
next ________days.
I (and my child(ren) am/are currently being court evicted from our housing at the address of
_____________________________________________________ and must leave this residence within the
next _________days.
I and my spouse/other (and my child(ren) are currently living at
_______________________________ _____________________ Shelter and have been living there for the
past ______________ days/months.
I certify that the information above and any other information I have provided to be true to the best
of my knowledge.
__________________________________________ ____________________________
Applicant Signature Date
____________________________________________ __________________________
Case Manager Signature Date
____________________________________________ ____________________________
Printed Name of Case Manager Agency Name
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Documentation of Homelessness Affidavit

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Completed 6 April 2022

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