Transcend STEM Third Party Verification of Homelessness

Third Party Verification of Homelessness
This form may be used by Transcend STEM Education as third party verification of homelessness to document that the applicant is currently homeless.

This section is to be completed by a Relevant Third-Party Representative:
I, First Name* Last Name* , as * (occupation/relationship to client) at * (organization/residency name) certify that * (client's name) is currently homeless and residing at * (address/location).
YesNo
Household without dependent childrenHousehold with dependent children
Number of persons in the household:*
By signing below,
I certify, under penalty of perjury, that the information provided above and any other information I have provided to be true. I understand that this information will be used to determine eligibility for a federally funded program and is subject to verification by the administrators of the program

I certify that the information provided above is completely true*
I understand that I may be contacted for future verification*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: