Who uses the Self-Certification of Homeless Status form?

An applicant or participant seeking Emergency Solutions Grants assistance uses it to certify homelessness or risk of homelessness when third-party documentation cannot be obtained.

Do I need a notary for the Self-Certification of Homeless Status form?

No. The applicant certifies under penalty of perjury and signs and dates the form; staff also sign and date their certification. No notary is indicated.

How do I submit the Self-Certification of Homeless Status form?

The form does not provide submission instructions. Submit it to the city department named on the form and check the city website for current contact details.

When should self-certification be used?

The form says self-certification should be used as a last resort if third-party documentation is not obtainable. Staff document attempts to obtain verification, except for emergency shelter.

Pasadena, TX · Harris County

No notary required

Self-Certification of Homeless Status

Applicants for Emergency Solutions Grants use this form to certify their household’s homelessness or risk of homelessness when third-party documentation cannot be obtained.

What this form is

This form records an applicant’s household information and self-certification of homelessness or risk of homelessness for Emergency Solutions Grants. It says to use self-certification as a last resort when third-party documentation is not obtainable. The applicant selects the applicable category and signs a declaration; staff record attempts to obtain third-party verification and certify their understanding of the verification requirements.

Who needs it

An applicant or participant seeking Emergency Solutions Grants assistance who cannot obtain third-party documentation of homelessness or risk of homelessness needs this form.

How to submit it

Submit it to the city department named on the form; check the city website for current contact details.

About notarization

This form is signed without a notary; the applicant certifies under penalty of perjury, and the applicant and staff member sign and date their respective sections.

How to submit this form

1
Download The Form
Download the Self-Certification of Homeless Status form.
2
Complete Applicant Information
Enter the applicant name, household information, and applicable homelessness or at-risk category.
3
Complete Verification Details
Staff record third-party verification attempts where required; the form says this documentation is not required for emergency shelter.
4
Sign And Date
The applicant signs and dates the client certification, and intake staff sign and date the staff certification.
5
Submit To The City
Submit it to the city department named on the form; check the city website for current contact details.

Frequently asked questions

Who uses the Self-Certification of Homeless Status form?: An applicant or participant seeking Emergency Solutions Grants assistance uses it to certify homelessness or risk of homelessness when third-party documentation cannot be obtained.
Do I need a notary for the Self-Certification of Homeless Status form?: No. The applicant certifies under penalty of perjury and signs and dates the form; staff also sign and date their certification. No notary is indicated.
How do I submit the Self-Certification of Homeless Status form?: The form does not provide submission instructions. Submit it to the city department named on the form and check the city website for current contact details.
When should self-certification be used?: The form says self-certification should be used as a last resort if third-party documentation is not obtainable. Staff document attempts to obtain verification, except for emergency shelter.

Need something notarized?

This Self-Certification of Homeless Status doesn’t need a notary — but Texas residents can notarize other documents online with a commissioned online notary.