Form SFN59247 "Esg/Ndhg Homeless Definition and Certification" - North Dakota

What Is Form SFN59247?

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 January 1, 2015;
  • 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 fillable version of Form SFN59247 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 SFN59247 "Esg/Ndhg Homeless Definition and Certification" - North Dakota

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ESG/NDHG HOMELESS DEFINITION AND CERTIFICATION
NORTH DAKOTA DEPARTMENT OF COMMERCE
DIVISION OF COMMUNITY SERVICES
SFN 59247 (1/15)
ESG Household Name
Date
This is to certify that the above i ndividual or household is currently homeless based on the category
checked and required documentation. ** THE GENERAL HOMELESS CERTIFICATION MUST BE COMPLETED
FOR EACH HOUSEHOLD.
CHRONICALLY HOMELESS CERTIFICATION
CHRONICALLY HOMELESS: (If chronically homeless, the General Homeless Certification Category 1, must
also be completed).
Individual or family:
(i) Has been homeless and living or residing in a place not meant for human habitation, a safe haven, or in an
emergency shelter continuously for at least one year or on at least four separate occasions in the last three
years; and
(ii) Has an adult head of household (or a minor head of household if no adult is present in the household) with a
diagnosable substance use disorder, serious mental illness, developmental disability (as defined in Section 102
of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002)), post-traumatic
stress disorder, cognitive impairments resulting from a brain injury, or chronic physical illness or disability,
including the co-occurrence of 2 or more of those conditions.
**GENERAL HOMELESS CERTIFICATION
**Category 1 is eligible for Rapid Re-housing Assistance
CATEGORY 1: Literally Homeless
Individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:
(i) Has a primary nighttime residence that is a public or private place not meant for human habitation; or
(ii) Is living in a publicly or privately operated shelter designated to provide temporary living arrangements
(including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations
or by federal, state and local government programs).
To certify homeless status for the above, must provide documentation of 1 of the following:
Written observation by the outreach worker; or
Written referral by another housing or service provider; or
Certification by the individual or head of household seeking assistance stating that (s)he was living on the
streets or in shelter (SFN 60319).
Individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:
(iii) Is exiting an institution where (s)he has resided for 90 days or less and who resided in an emergency shelter
or place not meant for human habitation immediately before entering that institution (documentation must
include one of the above forms of evidence AND 1 of the following).
Discharge paperwork or written/oral referral; or
Written record of intake worker’s due diligence to obtain above evidence and certification by individual that
they exited institution (SFN 60319).
**Categories 2 thru 4 are considered “homeless” but receive assistance under Prevention
CATEGORY 2: Imminent Risk of Homelessness
Individual or family who will imminently lose their primary nighttime residence, provided that:
(i) Residence will be lost within 14 days of the date of application for homeless assistance;
(ii) No subsequent residence has been identified; and
(iii) The individual or family lacks the resources or support networks needed to obtain other permanent housing.
ESG/NDHG HOMELESS DEFINITION AND CERTIFICATION
NORTH DAKOTA DEPARTMENT OF COMMERCE
DIVISION OF COMMUNITY SERVICES
SFN 59247 (1/15)
ESG Household Name
Date
This is to certify that the above i ndividual or household is currently homeless based on the category
checked and required documentation. ** THE GENERAL HOMELESS CERTIFICATION MUST BE COMPLETED
FOR EACH HOUSEHOLD.
CHRONICALLY HOMELESS CERTIFICATION
CHRONICALLY HOMELESS: (If chronically homeless, the General Homeless Certification Category 1, must
also be completed).
Individual or family:
(i) Has been homeless and living or residing in a place not meant for human habitation, a safe haven, or in an
emergency shelter continuously for at least one year or on at least four separate occasions in the last three
years; and
(ii) Has an adult head of household (or a minor head of household if no adult is present in the household) with a
diagnosable substance use disorder, serious mental illness, developmental disability (as defined in Section 102
of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002)), post-traumatic
stress disorder, cognitive impairments resulting from a brain injury, or chronic physical illness or disability,
including the co-occurrence of 2 or more of those conditions.
**GENERAL HOMELESS CERTIFICATION
**Category 1 is eligible for Rapid Re-housing Assistance
CATEGORY 1: Literally Homeless
Individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:
(i) Has a primary nighttime residence that is a public or private place not meant for human habitation; or
(ii) Is living in a publicly or privately operated shelter designated to provide temporary living arrangements
(including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations
or by federal, state and local government programs).
To certify homeless status for the above, must provide documentation of 1 of the following:
Written observation by the outreach worker; or
Written referral by another housing or service provider; or
Certification by the individual or head of household seeking assistance stating that (s)he was living on the
streets or in shelter (SFN 60319).
Individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:
(iii) Is exiting an institution where (s)he has resided for 90 days or less and who resided in an emergency shelter
or place not meant for human habitation immediately before entering that institution (documentation must
include one of the above forms of evidence AND 1 of the following).
Discharge paperwork or written/oral referral; or
Written record of intake worker’s due diligence to obtain above evidence and certification by individual that
they exited institution (SFN 60319).
**Categories 2 thru 4 are considered “homeless” but receive assistance under Prevention
CATEGORY 2: Imminent Risk of Homelessness
Individual or family who will imminently lose their primary nighttime residence, provided that:
(i) Residence will be lost within 14 days of the date of application for homeless assistance;
(ii) No subsequent residence has been identified; and
(iii) The individual or family lacks the resources or support networks needed to obtain other permanent housing.
CATEGORY 2: Imminent Risk of Homelessness (continued)
Documentation must include 1 of the following:
A court order resulting from an eviction action notifying the individual or family that they must leave; or
For individual and families leaving a hotel or motel—evidence that they lack the financial resources to stay
(SFN 60319); or
A documented and verified oral statement.
In addition to 1 of the above, documentation must include BOTH of the following:
Certification that no subsequent residence has been identified (SFN 60319); AND
Self-certification or other written documentation that the individual lack the financial resources and support
necessary to obtain permanent housing (SFN 60319).
CATEGORY 3: Homeless under Other Federal Statutes
Unaccompanied youth under 25 years of age, or families with children and youth, who do not otherwise qualify as
homeless under this definition, but who:
(i) Are defined as homeless under the other listed federal statutes;
(ii) Have not had a lease, ownership interest, or occupancy agreement in permanent housing during the 60 days
prior to the homeless assistance application
(iii) Have experienced persistent instability as measured by 2 moves or more during the preceding 60 days; and
(iv) Can be expected to continue in such status for an extended period of time due to special needs or barriers.
Documentation must include all of the following:
Certification by the nonprofit or state or local government that the individual or head of household seeking
assistance met the criteria of homelessness under another federal statute; and
Certification of no public housing in the last 60 days; and
Certification by the individual or head of household, and any available supporting documentation, that
(s)he has moved 2 or more times in the past 60 days; and
Documentation of special needs or 2 or more barriers.
CATEGORY 4: Fleeing/Attempting to Flee Domestic Violence
Any individual or family who:
(i) Is fleeing, or is attempting to flee, domestic violence;
(ii) Has no other residence; and
(iii) Lacks the resources or support networks to obtain other permanent housing.
Documentation required:
For victim service providers:
An oral statement by the individual or head of household seeking assistance which states: they are fleeing;
they have no subsequent residence; and they lack resources. Statement must be documented by a self-
certification (SFN 60319) or a certification by the intake worker.
For non-victim service provider (must document all of the following):
Oral statement by the individual or head of household seeking assistance that they are fleeing. This
statement is documented by a self-certification (SFN 60319) or by the caseworker. Where the safety of
the individual or family is not jeopardized, the oral statement must be verified; and
Certification by the individual or head of household that no subsequent residence has been identified
(SFN 60319); and
Self-certification, or other written documentation, that the individual or family lacks the financial resources
and support networks to obtain other permanent housing (SFN 60319).
Authorized Agency Representative Signature
Date
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