ࡱ> BDC bjbj 8( 8#,OwkX$;1RRRXRRRR6%LZjRG0wRI6IRIRRXwI : Homeless Prevention and Rapid Re-Housing Program (HPRP) HOMELESS CERTIFICATION HPRP Applicant Name: ______________________________________________  FORMCHECKBOX  Household without dependent children (complete one form for each adult in the household)  FORMCHECKBOX  Household with dependent children (complete one form for household) Number of persons in the household: _________ This is to certify that the above named individual or household is currently homeless based on the check mark, other indicated information, and signature indicating their current living situation. Check only one box and complete only that section Living Situation: place not meant for human habitation (e.g., cars, parks, abandoned buildings, streets/sidewalks)  FORMCHECKBOX  The person(s) named above is/are currently living in (or, if currently in hospital or other institution, was living in immediately prior to hospital/institution admission) a public or private place not designed for, or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus station, airport, or camp ground. Description of current living situation: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Homeless Street Outreach Program Name:_________________________________________________________________________ This certifying agency must be recognized by the local Continuum of Care (CoC) as an agency that has a program designed to serve persons living on the street or other places not meant for human habitation. Examples may be street outreach workers, day shelters, soup kitchens, Health Care for the Homeless sites, etc. Authorized Agency Representative Signature: _________________________________________ Date: ______________________  Living Situation: Emergency Shelter  FORMCHECKBOX  The person(s) named above is/are currently living in (or, if currently in hospital or other institution, was living in immediately prior to hospital/institution admission) a supervised publicly or privately operated shelter as follows: Emergency Shelter Program Name: _____________________________________________________________ This emergency shelter must appear on the CoCs Housing Inventory Chart submitted as part of the most recent CoC Homeless Assistance application to HUD or otherwise be recognized by the CoC as part of the CoC inventory (e.g. newly established Emergency Shelter). Authorized Agency Representative Signature: _________________________________________ Date: ______________________  Living Situation: Transitional Housing  FORMCHECKBOX  The person(s) named above is/are currently living in a transitional housing program for persons who are homeless. The persons(s) named above is/are graduating from or timing out of the transitional housing program: Transitional Housing Program Name: ____________________________________________________________ This transitional housing program must appear on the CoCs Housing Inventory Chart submitted as part of the most recent CoC Homeless Assistance application to HUD or otherwise be recognized by the CoC as part of the CoC inventory (e.g. newly established Transitional Housing program). Immediately prior to entering transitional housing the person(s) named above was/were residing in:  FORMCHECKBOX  emergency shelter OR  FORMCHECKBOX  a place unfit for human habitation Authorized Agency Representative Signature: _________________________________________ Date: ______________________      :;RSTc     ' 1 : ] Y ɾɾujj^TLjhkUUhd2:hkU5CJh*r:hkU5CJaJh*r:h.|CJaJ#jth*r:hkUCJUaJ#jh*r:hkUCJUaJh*r:hkUCJaJjh*r:hkUCJUaJh*r:h*r:CJaJh*r:h_CJaJh_CJaJhohkUCJ h*r:h*r:5CJ$aJh*r:5CJ$aJ h5Xh*r:h*r:5CJaJ;ST ] Y  78$(dRa$gdkUdgdkU$a$gdkU $<<a$gdo`gd.|gd_gdkUgd*r:       ! - I d ~ !/BEFMSwxy"#78CJZfkmph_h_5CJjhkUUh.| h.|6hIhkU6hz>}hkUh_jhIhkUUjhIhkUU h_hkUh_hkUCJh_h_5CJaJ hIhkU:2I^_tyz9:;]inps۹ɀɀɀɀɀxnh_h_5CJjhkUU hIh_hu.6B*phhu.hu.6B*phhu.hu.B*phhu.h.|6hu.hkU6hIhkU6hz>}hkUh_jhIhkUU hIhkUjhIhkUUh_h_5h_hkU5CJ*2:;&DE  $(dRa$gdogdu.dgdu.gd_$(dRa$gdkUdgd_dgdkUgdkU!8@D\&[^sxy#@CDERZcxػأzzrnnnnh*r:hu.hu.6hu.6B*phhu.hu.6B*ph hu.6hIh*r:6 h*r:6hIhkU6h*r:B*ph333hHB*ph333hIhkUB*ph333h_jhIhkUU hIhkUjhIhkUUhkUh_h_5CJ h_5CJ+   -9>@C]ah~귳h(jh(UhhjhkUUh_ hIhkUjhIh_Uh*r:j0hIh_U hIh_jhIh_UhkU$$(dRa$gdo61h:po@P / =!"#$% tDeCheck1tDeCheck2Dd \  3 S"`(0*88tDeCheck1Dd \  3 S"`(0*88hDeDd \  3 S"`(0*88tDeCheck1tDeCheck1tDeCheck1Dd \  3 S"`(0*88^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH D`D kUNormalOJQJ^J_HmH sH tH DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List d>d kUTitle,&dPOm$%@B* CJ4KHOJQJ^JaJ4ph6]^^ kU Title Char1@B* CJ4KHOJQJ_HaJ4mH ph6]sH tH HH u. Balloon TextCJOJQJ^JaJPK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] (     G$G$G$G$G$G$G$/XR$&"lboS,b$$bh,S@0(  B S  ? 33RRTYY8CJZ 9 ; D hQ)+'(d2:*r:n|;8AxFuNvOzz>}o^E[nG.|/HkUu.m$_W88V7Zt!1@@UnknownG* Times New Roman5Symbol3. * Arial7.{ @Calibri7K@Cambria5. *aTahomaA BCambria Math"1h4kF4kF*W *W !x4zz 2QHX ?kU2!xx Homeless Certification Form AlbaneseT Jen SlesingerOh+'0 , L X dpx Homeless Certification Form AlbaneseTNormalJen Slesinger2Microsoft Office Word@@R{%L@R{%L*W ՜.+,D՜.+,` hp  Abt Associates, Inc.z  Homeless Certification Form Title P (4Hh_AdHocReviewCycleID_NewReviewCycle_EmailSubject _AuthorEmail_AuthorEmailDisplayName_PreviousAdHocReviewCycleID_ReviewingToolsShownOnce6 cert langJulie.D.Hovden@hud.govHovden, Julie D'=  !"#$%&'()*+,./012346789:;<?Root Entry FL%LAData 1TableIWordDocument8(SummaryInformation(-DocumentSummaryInformation85CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89qRoot Entry F]?r:LGData 1TableIWordDocument8(  !"#$%&'()*+,./01234FE _AdHocReviewCycleID_NewReviewCycle_EmailSubject _AuthorEmail_AuthorEmailDisplayName_PreviousAdHocReviewCycleID_ReviewingToolsShownOnceSummaryInformation(-DocumentSummaryInformation8\CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q՜.+,D՜.+,` hp  Abt Associates, Inc.z  Homeless Certification Form Title