City of Dallas Declaration of Homelessness LinkedInThis field is for validation purposes and should be left unchanged.City of Dallas ESG Program: Declaration of HomelessnessCase No./Name:Date: MM slash DD slash YYYY Applicant InformationApplicant Name:* First Last Applicant Email Address: Date:* MM slash DD slash YYYY Applicant Social Security Number:*Date of Birth:* MM slash DD slash YYYY Homeless Declaration* I certify that: My household is “homeless”, as an individual or family who meets one of the categories below.Select the category that best describes the applicant's current situation:* Category 1: Literally Homeless; residing in a place not meant for human habitation Category 2: Imminent Risk of Homelessness; will imminently lose primary nighttime residence Category 3: Homeless Under Other Federal Statutes Category 4: Fleeing/Attempting to Flee DV For Category 1, the applicant is currently: Residing in a place not meant for human habitation (streets, cars, parks, sidewalks, abandoned buildings Residing in homeless shelters or treatment program Being discharged within a week from an institution or a jail/prison in which the person has been a resident for 90 days or less and no subsequent residence has been identified and lacks the resources and support networks needed to obtain housing Further InstructionsPlease download the City of Dallas Declaration 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
