NC ESG VERIFICATION OF AT RISK HOMELESSNESS FORM

Applicant: ______NC HMIS#:______Agency: ______

In all cases of homelessness, HUD has a preferred order for documentation. The best documentation to use is written, third (3rd ) party documentation, followed by oral 3rd party, followed by Intake Staff Observations (only applicable where indicated), and Self-Certification (only applicable where indicated.) Note: Self-Certification should be used as last resort if third party documentation is not obtainable. * Homelessness Prevention activities can only serve individuals and families that have an annual median income (AMI) at 30% or below and three month recertification is required for continued assistance

CRITERIA FOR DEFINING AT RISK OF HOMELESSNESS (Place an “X” in the correct ESG activity) Category 1 Category 2 Category 3 Individual and Families Unaccompanied Children and Youth Families and Children and Youth An individual or family who: A child or youth who does not qualify as homeless under An unaccompanied youth under 25 years of age who (i) Has an annual income below 30)% of median family income for the area; AND; the homeless definition, but qualifies as homeless under does not qualify as homeless under the homeless (ii) Does not have sufficient resources or support networks immediately available to prevent them from moving to another Federal statue. definition, but qualifies s homeless under section 725 an emergency shelter or another place defined in Category 1 of the “homeless” definition; AND (2) of the McKinney-Vento Homeless Act, and the (iii) Meets one of the following conditions: parents (s) or guardian (s) or that child or you if A. Has moved because of economic reasons 2 or more times during the 60 days immediately preceding the living with him or her. application for assistance; OR B. Is living in the home of another because of economic hardship; OR C. Has been notified that their right to occupy their current housing or living situation will be terminated with 21 days after the date of application for assistance; OR D. Lives in a hotel or motel and the cost is not paid for by charitable organization or by Federal, State, or local government programs for low income individuals; OR E. Lives in an SRO or efficiency apartment unit in which there reside more than 2 persons or lives in a larger housing unit in which there reside more than one and a half persons per room; OR F. Is exiting a publicly funded institution or system of care; OR G. Otherwise live in housing that has characteristics associated with instability and an increased risk of homelessness, as identified in the recipient’s approved Con Plan.

***Certify that the household lacks the financial resources and support necessary to obtain permanent housing. Yes: ______or No: ______

Verified by: ______Date: ______NC HMIS#:______

Agency MUST attach and submit third party documentation to support client’s verification of homelessness status (please list): ______

Refer to Interim ESG Regulation 24 CFR 576: Definition

1 Revised 1.25.17 1.3 NC ESG Verification of At Risk of Homelessness