Property Name:      						Minnesota Housing D#:      
Head of Household Name:      	Unit #:       

You have applied for or currently reside in a rental housing unit located in a property that received or will receive HIB financing from Minnesota Housing. This financing requires us (owner/agent) to rent units in the property to households with at least one individual who meets the definition of High Priority Homeless (HPH) or Other Homeless. Eligibility for households that meet the definition of HPH is documented by a Coordinated Entry Referral from the Housing Management Information System (HMIS). If you do not meet the definition of HPH, you may still be eligible as Other Homeless (defined below). Households who meet the definition of Other Homeless must complete this self-certification. 

Self-Certification of Other Homeless 	
I hereby certify that my household includes at least one person who lives/will live in the unit and meets the below definition of Other Homeless. 
Other Homeless: (i) individuals leaving institutions that do not have a permanent residence or (ii) homeless individuals not referred by the Coordinated Entry System. 
Refer to the HIB Other Homeless Eligibility Details page for more information. 

	     	     	
Signature of Head of Household	Printed Name of Head of Household	Date	
Providing false or misleading information may result in termination of tenancy. 

Service Provider Certification (for use only if Head of Household is unable to complete this self-certification)
Service Provider Organization Name:       
Service Provider Staff Phone Number and Email Address:      

The Head of Household is unable to complete the self-certification of eligibility. As the service provider for the above-named household, I am familiar with this household’s housing situation. I hereby certify that one or more persons who live/will live in the unit meets the above definition of Other Homeless.
	     	     	
Signature of Service Provider Staff	Printed Name of Service Provider Staff	Date	

Owner/Agent: Retain signed form in tenant file; submit to Minnesota Housing upon request.
Housing Infrastructure Bonds (HIB)
Other Homeless Eligibility Details

The following information is provided to assist in determining eligibility for units set aside for households that meet the definition of Other Homeless. 

Immediately prior to moving into the above property, the individual is/was without a fixed, adequate, nighttime residence or is leaving/has left institutional care or a correctional facility without a place to live. This includes:
•	Sleeping in emergency shelters, hotel, motel, outdoors, in a vehicle, abandoned building, bus or train station, airport, or camping ground
•	Doubled-up/couch-hopping (temporary stays with various friends and/or family)
•	Treatment facility, hospital, or foster care
•	Jail or prison

This person will benefit from the availability of supportive services because of multiple barriers to obtaining and maintaining housing.