IVERSITY
M.
ARKANSAS
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Phone:
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_______________________________________________ _________________________
Unaccompanied Homeless Youth Verification Form
Student Information:
Student Name: ______________________________________ Social Security Number: ___________________
Confirmation of Unaccompanied Homeless Status
You indicated on the “Dependency Status” section of your 2021-2022 Free Application for Federal Student Aid
(FASFA) that at any time on or after July 1, 2019 you were determined to be an unaccompanied youth who was
homeless or were an unaccompanied youth that is self-supporting and at risk of being homeless. Use this form to
confirm your status and attach supporting documentation.
I was determined to be an unaccompanied youth who was homeless as determined by one or more of
the organizations below and I have attached supporting documentation to this form.
Your high school or school district homeless liaison determined that you were an unaccompanied
youth who was homeless, or
The director of an emergency shelter program funded by the U.S. Department of Housing and
Urban Development (HUD) determined that you were an unaccompanied youth who was
homeless, or
The director of a runaway or homeless youth basic center or transitional living program (RHYA)
determined that you were an unaccompanied youth who was homeless or were self-supporting and
at risk of being homeless.
I was not determined to be an unaccompanied youth who was homeless by either of the organizations
above. But I am homeless or at-risk of homelessness and I am attaching other supporting
documentation from a recognized 3
rd
party such as: a homeless shelter or service provider, high
school counselor, health professional, social worker, employer, mentor, doctor, or clergy member.
I was not determined to be an unaccompanied youth who was homeless by either organization above.
However, I am unable to provide parental information on my FASFA or other financial aid forms
due to unusual circumstances and I would like to contact a school official to discuss my situation.
My signature below confirms that all of the information that I am providing on this form is true, accurate, and
complete.
Student’s Signature Date
Please visit https://www.uarichmountain.edu and click on the Financial Aid link for more information
and resources concerning unaccompanied youth and/or homelessness
click to sign
signature
click to edit
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