Declaration/Assessment of At-Risk of Homelessness LinkedInThis field is for validation purposes and should be left unchanged.HMIS ID (skip if you do not know):Date:* MM slash DD slash YYYY Applicant InformationApplicant Name:* First Last Applicant Email Address: Date:* MM slash DD slash YYYY Date of Birth:* MM slash DD slash YYYY At Risk of Homelessness Certification* I certify that: My household is “at risk of homelessness".Please select the category that best describes the applicant's current situation:* Category 1: Individuals and Families - annual income below 30% of AMI, does not have sufficient resources or support networks immediately available, meets one of the risk conditions Category 2: Homeless Children and Youth - Child or youth who does not qualify as homeless under the homeless definition, but qualifies as homeless under another Federal statute Category 3: Homeless Children and Youth - Youth who does not qualify as homeless under the homeless definition, but qualifies as homeless under 725(2) of the McKinney-Vento Homeless Assistance Act, and the parent(s) or guardian(s) of that child or youth if living with him or her Please select the appropriate Category 1 risk below: Risk 1: : Persistent housing instability due to economic reasons; housing history must demonstrate 2 or more moves within 60 days Risk 2: Living in a home of another because of economic hardship (doubled up) Risk 3: Housing loss within 21 days Risk 4: Living in a rented hotel or motel Risk 5: Living in a severely over-crowded unit as defined by the U.S. Census Bureau Risk 6: Exiting publicly funded institution or system of care Further InstructionsPlease download the Declaration/Assessment of At-Risk of Homelessness document from Family Gateway's website to review the required documentation for each category or ask your caseworker.Certification* I certify and acknowledge that the information provided here will be used to determine my eligibility and amount of assistance and that the information is true and correct to the best of my knowledge. This information is subject to verification, and falsification of this information may be grounds for termination from the program and result in prosecution under federal and state laws.E-Signature of Applicant (please type your name in the box below):*Date:* MM slash DD slash YYYY To be signed by Caseworker AFTER SUBMISSIONSignature of Caseworker:Date: MM slash DD slash YYYY
