Instructions: This form is to be completed by applicants or program participants when they are unable to provide
required verifications or other documents and self-certification is the only way the agency is able to verify
information related to the ESG/CDBG program eligibility. There must be documentation attached to this form
showing all efforts were made to obtain the necessary information.
This Section is to be completed by the applicant/participant
Date: ___________ Program Name: ______________________ CDBG ESG-HMIS #__________
Applicant Name: ____________________________
Address: ___________________________________________________
Telephone Number: ______________ E- mail Address: ____________________________
Household without dependent children (complete one form for each adult in the household)
Household with dependent children (complete one form for each adult in the household)
Number of persons in the household: ______
This is to certify that the above named individual or household is currently homeless or at-risk of
homelessness, based on the following and other indicated information and the signed declaration by
the applicant.
Check only one:
I (and my children) am/are currently homeless and living on the street (i.e. a car, park, abandoned
building, bus station, airport or camp ground).
Exited an institution, causing homelessness
I (and my children) am/are the victim(s) of domestic violence and am/are fleeing from abuse.
I (and my children) am/are being evicted from the housing we are presently staying in and must
leave this housing within the next _____ days.
Other, Please describe
Certification: I hereby certify, under penalty of perjury, that the information I have provided on this
form is true and correct, to the best of my knowledge, and that I do not have any documents or forms in
my possession, nor am I able to obtain such documents to verify homelessness, at risk of homelessness,
income or other information hereby provided.
**Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
Applicant Signature: ___________________________________ Date: ______________________
Intake Staff Signature: ___________________________________ Date: ______________________