AMETHYST HOUSE
RESIDENTIAL- WOMEN'S PROGRAM ONLY
HOMELESS STATUS VERIFICATION

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Please fill out and return to Amethyst.

Name: _____________________________
Date: _____________________________
Social Security Number: _____________________________

Check the circumstances applicable:

_____ *person sleeping in places not meant for human habitation, such as cars, parks, sidewalks, and abandoned buildings
_____ *person sleeping in emergency shelters
_____ *person leaving transition or supportive housing for homeless persons who originally came from streets or emergency shelters
*This includes persons who ordinarily sleep in one of the above places but are spending a short time (30 consecutive days or less) in a hospital or other institution
_____ person being evicted within the week from private dwelling units and no subsequent residences have been identified and she/he lacks the resources and support networks needed to obtain access to housing
_____ person being discharged within the week from an institution in which she/he has been a resident for more than 30 consecutive days and no subsequent residences have been identified, and she/he lacks the resources and support networks needed to obtain access to housing

HOMELESSNESS STATUS IS BASED ON HUD GUIDELINES

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Copyright: Amethyst House

E-mail: amethyst@bloomington.in.us
(812) 336-3570

Last Updated: Wednesday, October 26, 2005