This is an optional form to use for a referral or to provide evidence to support the Long-Term Homelessness Eligibility form. 

Instructions

•	The form can be completed by one service provider who is referring a household to another service provider, by a street outreach team to a housing provider, or by a friend or family member who is verifying that the applicant stayed with them in order to avoid living on the streets or in a shelter.  
•	For Type of Living Situation, choose from: emergency shelter, living on the street, staying with friends/family, place not meant for human habitation, or other (specify).  

Print Applicant Name	     	

Start/End
Dates	Type of Living Situation	City and State
AND
Facility Name OR Address	Reason for Leaving	
     	     	     	     	
     	     	     	     	
     	     
	     	     	
     	     	     	     	

Comments	
     	

Third Party Signature
I verify the information provided on this form is accurate and true.

Print Name:                                                                        Title or Relationship to Applicant:       	
Company/Agency Name and Address (if applicable):                                                     Telephone Number:                                             Fax:                                     Email:      

	     	
Signature	Date