Homeless Status Certification Form

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Office of the Secretar y of State
2701 S. DIRKSEN PKWY.
SPRINGFIELD, IL 62723
Driver Ser vices Depar tment
800-252-8980
Homeless Status Certification
The Homeless Status Certification is provided for the listed agent or agency to affirm to the named individual’s homelessness at
the time this certification is completed. It must be received by the Illinois Secretary of State’s office at the time of application no
later than 90 days from date notarized. This certification entitles the individual to a free standard State of Illinois ID Card.
This form does not establish proof of the applicant’s name, date of birth or Social Security numbers, as required by Illinois law to
obtain a State ID Card. The applicant must provide separate documentation from the list of approved documents by the Illinois
Secretary of State at the time of application.
Homeless Status Certification
Applicant’s Name (First, Middle, Last):
Applicant’s Date of Birth:_________________________________
Under penalty of perjury, I swear or affirm that:
I am a homeless individual as defined by federal law and I currently reside at or receive services from the Agency whose name and
address are indicated on this document. I understand that the Illinois State Identification Card (ID Card) for which I am applying
will be delivered to this Agency at the address listed on this document and I must pick up the ID Card from the Agency within
sixty (60) days of the Agency’s receipt of the document. If I fail to collect the ID Card within this 60-day period, it will be returned
to the Illinois Secretary of State.
Signature of Applicant
Date
State of Illinois County of: ________________________________________
Subscribed and sworn to before me this ______________ day of ______________________________ , 20 _______ .
______________________________________________________
(Place Notary Stamp Here)
Notary Public
Making any false statement on this certification is punishable by law.
Printed by authority of the State of Illinois. — June 2016 — 1 — DSD A 230.2

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