HOME20
UNACCOMPANIED OR HOMELESS YOUTH VERIFICATION
(2019-2020 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 finaid@coconino.edu
FA-109-HOME20 20181003
Youth Housing Information (to be completed by a Youth Housing Official- Please Print)
Youth Housing Official Full Name
Affiliation (Please check one)
□ McKinney-Vento School District
□ Director or designee of an HUD-
□ Director or designee of an RHYA-
According to the College Cost Reduction and Access Act (Public Law 110-84), I, the official listed above, am
authorized to verify the above student’s living situation. Should you have more questions or need more
information about this student, please contact our office at the number listed above.
I confirm the following about the student listed above (please check one):
The Student is… Definition
□
An unaccompanied homeless youth
after July 1, 2018.
After July 1, 2018, the student was living in a homeless situation, as
defined by Section 725 of the McKinney-Vento Act, and was not in
the physical custody of a parent or guardian.
□
An unaccompanied self-supporting
youth at risk of homelessness after
After July 1, 2018, the student was not in the physical custody of a
parent or guardian, provides for his or her own living expenses
entirely on his or her own, and is at risk of losing his or her housing.
CERTIFICATION STATEMENT & SIGNATURES
I certify that the information provided on this form is complete and accurate to the best of my knowledge. I understand that submission
of false information may result in a delay or denial of federal financial aid and may subject me to criminal charges. I understand that
purposely giving false or misleading information may result in a fine of up to $20,000, being sent to prison, or both.
Youth Housing Official Signature
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address
