This form is required to verify eligibility for Long-Term Homelessness (LTH) and must be kept in the tenant file of the housing provider. 

Verification Steps

The service provider/assessor who completes this form should:
•	List two to four years of all housing history below, starting with the most recent date. Approximate dates (month/year) may be used, and intermittent shelter stays (e.g., within one month) may be grouped together. If necessary, continue to list living situations on page three.
•	For type of living situation, choose from: emergency shelter, transitional housing, psychiatric facility, substance abuse treatment, hospital, jail/prison, staying with friends/family, rental housing, a place not meant for human habitation, or other (specify).  
•	The agency documenting LTH eligibility must attempt to verify each homeless episode and attach a paper copy of the evidence to this form. Verification may be via: letter, Third Party Verification Form, email, phone conversation (include date, name and number of the person you talked to), or evidence in HMIS or another database.
•	If third party verification is not feasible for one or more of the homeless episodes, the applicant may self-certify. List “self-cert” in the verification type, and explain in the comments section why third party verification is not possible.

Print Applicant Name	     	

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

Comments/Notes/Reason For Self-Certification	

Important! Eligibility requirements for homeless status depend on the type of program. 

Households Experiencing Long-Term Homelessness:  Persons, including individuals, unaccompanied youth, and families with children who lack a permanent place to live continuously for a year or more or at least four times in the past three years. Exclude any period of institutionalization, incarceration, or transitional housing when determining the length of time a household has been homeless.  

Households at Significant Risk of Long-Term Homelessness:  Includes (a) households that are homeless or recently homeless that have members who were previously homeless for extended periods of time and are faced with a situation or a set of circumstances likely to cause the household to become homeless in the near future, or (b) previously homeless persons who will be discharged from correctional, medical, mental health or treatment centers who lack sufficient resources to pay for housing and who do not have a permanent place to live.

For more information, please read: LTH Definition Eligibility Common Questions found at mnhousing.gov.
 
Applicant Verification

I verify the information provided on this form is accurate and true.
	
Print Name:       	
Telephone Number:       
Email:      

	     	
Signature	Date	
			
Service Provider Determination

I have determined that the applicant:  	

 Meets the definition of long-term homelessness
 Meets the definition of significant risk of long-term homelessness
 Does not meet either definition 

Print Name:            
Title of Professional:       
Company/Agency Name and Address:       	
Telephone Number:      	Fax:      	Email:      	
			
	       	
Signature                                                                                                    Date		

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

Comments/Notes/Reason For Self-Certification