Amethyst House- Homeless Status Verification

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

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

Comments / Other Pertinent Information:

Name:	_____________________________
Date:	_____________________________
Social Security Number:	_____________________________

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

Check the circumstances applicable:

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