Scsep Third Party Attestation Forms - U.s. Department Of Labor Page 8
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12Third-Party Attestation Form for Item P27
At risk of homelessness?
Homelessness here is defined according to element P8 – Homeless, which states that participant is homeless if
he or she:
1. lacks a fixed, regular, and adequate nighttime residence; and
2. has a primary nighttime residence that is:
a. a supervised publicly or privately operated shelter designed to provide temporary living
accommodations (including welfare hotels, congregate shelters, and transitional housing for
the mentally ill);
b. an institution that provides a temporary residence for individuals intended to be
institutionalized; or
c. a public or private place not designed for, or ordinarily used as, a regular sleeping
accommodation for human beings.
On this date, I attest that the following specific conditions
place __________________________________________
at risk of homelessness:
(Name of Applicant)
_____His or her rent/mortgage is unpaid or overdue;
_____She / he often borrows to pay rent/mortgage;
_____His / her real estate taxes are unpaid or overdue;
_____She/he is temporarily sharing space with a family or friend;
_____He/she has involuntarily moved several times in last year;
_____Her/his credit history or background disqualifies her/him from most rental/lease agreements;
_____He/she cannot pay rent/mortgage most months;
_____She /he frequently has unpaid or overdue electric/gas/water bills;
_____He/she has been evicted from a residence in the last 12 months;
_____She/he has lived in a shelter during the past 12 months
Specific information about your relationship to the applicant and an explanation of how you are in a
knowledgeable position to attest to the facts cited above is required. Please provide this information below
(Note: Use the back of this form if additional space is needed):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________________
_____________________________________
(Name of Attesting Individual)
(Relationship of Attesting Individual to Applicant)
_____________________________________
___________________
(Signature of Attesting Individual)
(Date)
SCSEP Third Party Attestation Forms
page 8 of 12
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