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HOMELESSNESS CERTIFICATION FOR WNOMII:31WA EMERGENCY HOUSING VOUCHERS Client Name: Number of Adults in Household: ' oor ina e ENTRY SYSTEM Date of Birth: Number of Minor Children in Household: This is to certify the above -named person's or household's current living situation. This certificate must be completed by an agency recognized by the Continuum of Care (CoC) as having a program designed to serve persons living on the street or other places not meant for human habitation, appears on the CoC's Housing Inventory Chart or is otherwise recognized by the CoC as part of the CoC inventory. Please check only one section. Living Situation: place not meant for human habitation (e.g., cars, parks, abandoned buildings, streets/sidewalks) The person(s) named above is/are currently living in (or, if currently in hospital or other institution for less than 90 days, was living in immediately prior to hospital/institution admission) a public or private place not designated for, or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus station, airport, or camp ground. Living Situation: Emergency Shelter The person(s) named above is/are currently living in (or, if currently in hospital or other institution for less than 90 days, was living in immediately prior to hospital/institution admission) a supervised publicly or privately operated shelter. Living Situation: Recently Homeless The person(s) named above is/are currently receiving financial and supportive services for persons who are formerly homeless and were living in emergency shelter or a place not meant for human habitation immediately prior to program enrollment. Loss of such assistance would result in a return to homelessness. I certify that that the information reported above is accurate and correct. Name: Title: Signature: City Council Phone #: Agency: Date: 31 — 31 version 06/25/2021 Page 24 of 29