Coc Program Participant Disability Verification Form printable pdf download

Coc Program Participant Disability Verification Form

CoC Program Participant

Disability Verification Form

PART 1: INSTRUCTIONS

 To be eligible for all CoC funded PSH, evidence that one or more members of the household is

diagnosed with a disability must be documented in the participant file.

 To be eligible for a PSH unit that is dedicated to serve chronically homeless people, the

disability must be documented for an adult head of household, or, if there is no adult in the

family, a minor head of household.

 This form can also be used for CoC-funded TH or other programs that have committed to

serving disabled people.

 Complete all fields in Part 2.

 Complete all fields under the relevant option in Part 3

 Attach all supporting documents to this form.

 Maintain this form and all supporting documents in the participant’s file.

PART 2: GENERAL INFORMATION

CoC Project Name:

Admitting CoC Agency Name:

Date of

CoC Project

Participant Name:

HMIS #

Birth

Entry Date

Part 3: DISABILITY CERTIFICATION

Option #1: Social Security (SSI/DI) or Veteran’s Disability

Evidence must include one of the following (Check One):

A) Written verification from the Social Security Administration; OR



B) Copies of a disability check (e.g., SSI, SSDI or Veterans Disability Compensation)



ATTACH EVIDENCE OF EITHER A OR B TO THIS FORM

Check here to indicate that evidence



has been attached.

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Coc Program Participant Disability Verification Form