Form SFN60319 "Esg/Ndhg Self Certification" - North Dakota

What Is Form SFN60319?

This is a legal form that was released by the North Dakota Department of Commerce - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2013;
  • The latest edition provided by the North Dakota Department of Commerce;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SFN60319 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Commerce.

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Download Form SFN60319 "Esg/Ndhg Self Certification" - North Dakota

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ESG/NDHG SELF CERTIFICATION
ND DEPARTMENT OF COMMERCE/DIVISION OF COMMUNITY SERVICES
SFN 60319 (06/13)
Instructions: This form is to be completed by applicants or program participants when they are unable to
provide the ND Division of Community Services required verifications or other documents and self-certification is
the only way the agency is able to verify information related to the ESG/NDHG eligibility.
This section to be completed by the applicant/participant
Date
Name of Head of Household
Address
City
State
ZIP Code
Telephone Number
Email Address
Self-Certification of:
Lack of sufficient financial resources and/or support networks and no subsequent residence has
been identified
Fleeing domestic violence
Exiting from institution
Living on street or in shelter
Other (please describe below):
Certification: I hereby certify, under penalty of perjury, that the information I have provided on this form is true
and correct, to the best of my knowledge, and that I do not have any documents or forms in my possession, nor
am I able to obtain such documents to verify homelessness, at risk of homelessness, income or other
information hereby provided.
Client Signature
Date
Intake Staff Signature
Date
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false
statements or misrepresentations to any department or Agency of the United States as to any matter
within its jurisdiction.
ESG/NDHG SELF CERTIFICATION
ND DEPARTMENT OF COMMERCE/DIVISION OF COMMUNITY SERVICES
SFN 60319 (06/13)
Instructions: This form is to be completed by applicants or program participants when they are unable to
provide the ND Division of Community Services required verifications or other documents and self-certification is
the only way the agency is able to verify information related to the ESG/NDHG eligibility.
This section to be completed by the applicant/participant
Date
Name of Head of Household
Address
City
State
ZIP Code
Telephone Number
Email Address
Self-Certification of:
Lack of sufficient financial resources and/or support networks and no subsequent residence has
been identified
Fleeing domestic violence
Exiting from institution
Living on street or in shelter
Other (please describe below):
Certification: I hereby certify, under penalty of perjury, that the information I have provided on this form is true
and correct, to the best of my knowledge, and that I do not have any documents or forms in my possession, nor
am I able to obtain such documents to verify homelessness, at risk of homelessness, income or other
information hereby provided.
Client Signature
Date
Intake Staff Signature
Date
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false
statements or misrepresentations to any department or Agency of the United States as to any matter
within its jurisdiction.