Pasadena, TX · Harris County
Third Party Certification of Homelessness/Domestic Violence
This form lets an authorized agency representative document the housing status of an individual or household seeking Emergency Solutions Grants assistance.
What this form is
ESG subrecipients may use this form when agency letterhead documentation is unavailable to document the housing status of an individual or household seeking assistance. An authorized person from the agency that provided housing or services completes Option 1 for a facility or program stay, or Option 2 for an unsheltered living situation. The form asks for participant and household details, housing information, and the verifying representative’s contact information and signature.
Who needs it
An authorized representative of the agency that provided housing or services completes this form for an ESG applicant when agency letterhead documentation is unavailable.
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 document is signed without a notary; the authorized agency representative signs and dates the certification.
How to submit this form
- 1
Download the Form
Download the Third Party Certification of Homelessness/Domestic Violence PDF.
- 2
Complete Participant Details
Enter the participant name, identifier, program entry date, household details, and choose Option 1 or Option 2.
- 3
Describe Housing Status
Complete the selected option with facility or program stay details, or describe the current unsheltered living situation.
- 4
Sign and Submit
The authorized agency representative enters their details, signs and dates the form, then submits it to the city department named on the form.
Frequently asked questions
- Who completes the Third Party Certification of Homelessness/Domestic Violence?
- Only an authorized individual from the agency that provided housing or services to the applicant can complete the form.
- Which option should the agency representative complete?
- Complete Option 1 to document a stay at a facility or program, or Option 2 to document an unsheltered living situation.
- Do I need a notary for the Third Party Certification of Homelessness/Domestic Violence?
- No. The document is signed without a notary; the authorized agency representative signs and dates the certification.
- How do I submit the Third Party Certification of Homelessness/Domestic Violence?
- 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.
Need something notarized?
This Third Party Certification of Homelessness/Domestic Violence doesn’t need a notary — but Texas residents can notarize other documents online with a commissioned online notary.