Benton Harbor, MI 49022
Phone: 269-927-8112/ Fax: 269-927-8183
Email: finaid@lakemichigancollege.edu
Unaccompanied Homeless Youth Verification Form
Student Information
First Name:
Last Name:
Middle name:
Student ID Number:
Mailing Address:
City:
Background Information
State: Zip:
When you completed your 2020-2021 Free Application for Federal Student Aid (FAFSA), you answered yes to
one of the unaccompained homeless youth questions. Please complete this verification form and submit to the
Financial Aid Office with certification from the appropriate agency verifying your homeless status.
Definitions:
Homeless means lacking fixed, regular and adequate housing, which includes living in shelters, motels,
cars, or temporarily living with other people.
Unaccompanied means you are not living in the physical custody of your parent or guardian.
Youth means you are 21 years or younger or you are still enrolled in high school as of the day you signed
the FAFSA.
Student Section:
1. If you check one of the three boxes below, you must provide documentation by submitting page 3 of this
document *.
Unaccompanied Youth who was homeless determined by high school or school district homeless liaison
Unaccompained Youth who was homeless determined by HUD ( U.S. Dept. of Housing & Urban
Development)
Unaccompained Youth was was homeless and at risk of being homeless determined by homeless youth
basic center or transitional living program
2. If you living situation cannot be verified by the above agencies, does your living situation meet the following
definition?
I am homeless meaning lacking, regular or adequate housing, which includes living in shelters,
motels, cars, or temporarily living with other people “couch surfing”.
Yes No
If you answered “Yes” to question #2, you must submit a letter, a detailed statement of your current
living situation along with this form.
Student Certification
I certify that all information on this form is true, complete, and accurate. Upon request, I agree to provide proof of
the information reported on this form. False statements or misrepresentation can be considered a cause for denial,
reduction, withdrawal, and/or repayment of financial aid. I give permission to the Financial Aid Office to make
corrections/adjustments to my data the the FAFSA based on forms and/or documents submitted.
Student Signature: Date:
*PLEASE NOTE*
Once all pages or supporting documentation has been completed, please submit them to Lake Michigan
Colleges Financial Aid Office for review.
SECTION TO BE COMPLETED BY CERTIFYING OFFICIAL ONLY
Contact Information for Certifying Official
Name:
Phone Number:
Mailing Address:
City: State: Zip:
I am providing this letter of verification as (check one)
McKinney-Vento School District Liaison
Director or designee of a HUD-funded shelter
Director or designee of a RHYA-funded shelter (Runaway & Homeless Youth Act)
As per the College Cost Reduction and Access Act (Public Law 110-84), I am authorized to verify this student’s
living situation. No further verification by the Financial Aid Administrator is necessary. Should you have
additional questions or need more information about this student, please contact me at the number listed above.
This letter is to confirm that was (please check one below):
An unaccompanied homeless youth on or after July 1, 2019.
This means that on or after July 1, 2019, the student was living in a home 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 on or after July 1, 2019.
This means that, on or after July 1, 2019, the student was not in the physical custody of a parent or
guardian, provides for their own living expenses entirely on their own, and is at risk of losing their housing.
Signature: Date:
TO BE COMPLETED BY CERTIFYING OFFICIAL ONLY
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