Homeless Verification Form

July 21, 2011

A homeless verification form is a document to prove that a certain individual is homeless and has no place to stay. This form is filled so that the individual gets a place to reside after referred by an agency.

Sample Homeless Verification Form:

Name of the individual: First name __________ Middle name _______ Surname _______

Name of person referring the individual:  _________________________

Name of the referring Agency: ________________

I would like to inform that the person to whom I am referring is homeless. His daily residence includes:

  • Places unsuitable for human habitation like car parks, sidewalks and abandoned buildings.
  • He also sometimes resides in an emergency shelter:

Name of the shelter: ________

Address of the shelter: ___________________________

  • He was also residing in a mental institution for a period of thirty days. He has been discharged now, but has no means to obtain a shelter. Details of the mental institution:

Name: __________

Address: ____________________


Signature of Individual Making referral:

Dated: __________


Guest Signature

Dated: ____________


Download Homeless Verification Form in Word Format

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