Fillable Driver Services Department (Illinois Secretary of State)

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Driver Services Department (Illinois Secretary of State)

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Homeless Status Certification
The Homeless Status Certification is provided for the listed agent or agency to affirm to the named individual’s homelessness at
the time this certification is completed. It must be received by the Illinois Secretary of State’s office at the time of application no
later than 90 days from date notarized. This certification entitles the individual to a free standard State of Illinois ID Card.
This form does not establish proof of the applicant’s name, date of birth or Social Security numbers, as required by Illinois law to
obtain a State ID Card. The applicant must provide separate documentation from the list of approved documents by the Illinois
Secretary of State at the time of application.
Homeless Status Certification
Applicant’s Name (First, Middle, Last):
Applicant’s Date of Birth:_________________________________
Under penalty of perjury, I swear or affirm that:
I am a homeless individual as defined by federal law and I currently reside at or receive services from the Agency whose name and
address are indicated on this document. I understand that the Illinois State Identification Card (ID Card) for which I am applying
will be delivered to this Agency at the address listed on this document and I must pick up the ID Card from the Agency within
sixty (60) days of the Agency’s receipt of the document. If I fail to collect the ID Card within this 60-day period, it will be returned
to the Illinois Secretary of State.
Signature of Applicant Date
State of Illinois County of:
________________________________________
Subscribed and sworn to before me this ______________ day of ______________________________ , 20 _______ .
______________________________________________________
Notary Public (Place Notary Stamp Here)
Making any false statement on this certification is punishable by law.
Printed by authority of the State of Illinois. — June 2016 — 1 — DSD A 230.2
Office of the Secretary of State
Driver Services Department
2701 S. DIRKSEN PKWY.
SPRINGFIELD, IL 62723
800-252-8980
www.cyberdriveillinois.com
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Agency Name: ___________________________________________________________________________________________
Agency Address: _________________________________________________________________________________________
Street (Mailing Address)
_______________________________________________________________________________________________________
City Zip Code
_______________________________________________________________________________________________________
Agency Phone Number (including Area Code)
_______________________________________________________________________________________________________
Agency Federal Tax ID Number or Attorney Registration Number
***
Under penalty of perjury, I swear or affirm that I am a representative of the above-referenced Agency and the applicant is a
homeless person who is currently residing or receiving services from this Agency.
I acknowledge that I accept responsibility for this Agency to receive, by United States mail, and hold in a secure location the
ID Card issued to the applicant and will make every effort to ensure the delivery of the ID Card to the applicant when (s)he pres-
ents himself/herself in person to the Agency.
Should the applicant not return to the Agency to pick up the ID Card within sixty (60) days of its receipt in this office, the
Agency will return the ID card to the Illinois Secretary of State by marking the envelope “Return To Sender” and depositing it
in the United States mail.
Date:_____________________________
________________________________________________________________________
Printed Name of Agency Employee Making Certification
________________________________________________________________________
Signature of Agency Employee Making Certification
State of Illinois County of:
________________________________________
Subscribed and sworn to before me this ______________ day of ______________________________ , 20 _______ .
______________________________________________________
Notary Public (Place Notary Stamp Here)
Making any false statement on this certification is punishable by law.
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Driver Services Department (Illinois Secretary of State)

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Completed 9 August 2021

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