Homeless Status Certification Form Page 2
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2Agency Name: ___________________________________________________________________________________________
Agency Address: _________________________________________________________________________________________
Street (Mailing Address)
_______________________________________________________________________________________________________
City
Zip Code
_______________________________________________________________________________________________________
Agency Phone Number (including Area Code)
_______________________________________________________________________________________________________
Agency Federal Tax ID Number or Attorney Registration Number
***
Under penalty of perjury, I swear or affirm that I am a representative of the above-referenced Agency and the applicant is a
homeless person who is currently residing or receiving services from this Agency.
I acknowledge that I accept responsibility for this Agency to receive, by United States mail, and hold in a secure location the
ID Card issued to the applicant and will make every effort to ensure the delivery of the ID Card to the applicant when (s)he pres-
ents himself/herself in person to the Agency.
Should the applicant not return to the Agency to pick up the ID Card within sixty (60) days of its receipt in this office, the
Agency will return the ID card to the Illinois Secretary of State by marking the envelope “Return To Sender” and depositing it
in the United States mail.
Date:_____________________________
________________________________________________________________________
Printed Name of Agency Employee Making Certification
________________________________________________________________________
Signature of Agency Employee Making Certification
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.
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