Unaccompanied Homeless Youth Determination Form
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1Unaccompanied Homeless Youth
Determination Form
Financial Aid Services
2016-2017
For the Purpose of Applying for Financial Aid
Student’s Name: __________________________________________________________ SPIRE ID#: __________________________
Last, First Middle
Current Mailing address:__________________________________________________________ Phone #: (
) _______-_________
If you are an unaccompanied homeless youth, or an unaccompanied self-supporting youth at risk of homelessness, complete Box 1 or Box 2,
sign the certifi cation below, attach required documentation, and submit to Financial Aid Services. If you are unsure if your living
situation meets the defi nition of homelessness or at risk of homelessness or determination was made prior to July 1, 2015, contact
Financial Aid Services at 413-545-0801.
BOX 1 -
To be completed by the person providing the determination
This form is to confi rm that the above named student is considered to meet the requirements to be an unaccompanied homeless youth
for the purpose of applying for Federal fi nancial aid. This means that after July 1, 2015, the student was:
√
Check one
An unaccompanied homeless youth - The student was living in a homeless situation, as defi ned by Section 725 of the
McKinney-Vento Act, and was not in the physical custody of a parent or guardian.
An unaccompanied, self supporting youth at risk of homelessness - The student is not in the physical custody of a parent
or guardian, provides for his/her own living expenses entirely on his/her own, and is at risk of losing his/her housing.
√
I am completing this form of determination as a (
Check one):
McKinney-Vento School District Liaison
Director or designee of a HUD-funded shelter
Director or designee of a RHYA-funded shelter
Other: Director or designee of homeless shelter or educational agency
Name (please print): ______________________________________________________Title:__________________________________________
Organization/School Name: _____________________________________________________ _________________________________________
Address: ______________________________________________________________________________________________________________
City: _______________________ State: _________ Zip Code: ____________
Telephone#: (
) ______-_________
As per the College Cost Reduction and Access Act (Public Law 110-84), I am authorized to verify this student’s living situation. No further verification
by the Financial Aid Administrator is necessary. Should you have additional questions or need more information about this student, please contact
me at the number listed above.
BOX 2
Complete this section if you do not have a determination as described in Box 1, but you are an unaccompanied youth who is
.
homeless or are an unaccompanied youth providing for your own expenses and at risk of being homeless
Check here and attach a signed letter of explanation
from yourself and a letter from a person with whom you have temporarily lived,
or who knows of your situation, explaining your circumstances and how they know you. This could be a high school counselor,
mental health professional, social worker, mentor, doctor, or clergy.
Returning Students: To continue your status as an independent student, attach an updated personal statement that describes your
current living /housing situation. All information submitted will remain confi dential.
CERTIFICATION
By signing this form, you are certifying that all information being reported here and all supporting documentation you are submitting is complete
and correct. If you purposely give false or misleading information on this form you may be fined, be sentenced to jail, or both.
_______________________________________________________
Signature
Date
Fax completed, signed form to: 413-545-1700
*FHMLSO*
or email completed, signed form to: fadocs@fi naid.umass.edu
(Attachments must be a standard image fi le, or in one of the following fi le formats: .doc, .docx, .pdf)
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