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About Us
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Board of Directors
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Get Involved
Volunteer
Volunteer Sign Up
Take A Tour
Request A Speaker
Need Help?
Are You Homeless?
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Qualifying Disability & Homelessness Verification
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Qualifying Disability and Homelessness Verification
Eden Village defines a chronically homeless person as – an unaccompanied homeless person (a single homeless person who is along and is no part of a homeless family and not accompanied by children) that meets 3 specific criteria. The following questions will determine your eligibility for Eden Village.
Complete Legal Name
*
First
Middle
Last
Email
Cell Phone
Work Phone
Part 1: A Disabling Condition
Do you have any disabilities?
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No
Yes
What are your disabilities? Check all that apply.
*
Alcohol Abuse
Alzheimer’s Disease/Dementia
Cognitive
Developmental
Drug Abuse
Hearing
HIV/AIDS
Learning
Mental Handicap/Injury
Mental Illness
Physical/Medical
Physical/Mobility
Visual
Speech
Other
Other Disabilities
*
What medical or mental diagnosis do you have?
*
Are each of the disabilities listed above expected to be of a long, continued and indefinite duration and substantially impair your daily life?
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Yes
No
Which disabilities do not?
*
Which of the above disabilities are you currently in treatment for?
*
Part II: Duration in Tulsa Metropolitan Area
How long have you lived in the Tulsa Metropolitan Area?
*
Part III: Chronically Homeless Status
Knowing that…
Episodes (“occasions”) of homelessness are broken up by and period of time where the client was housed for 7 days or more
Transitional housing and hotels or motels paid for by the client are classified as housing for those eligibility purposes
The following are classified as emergency shelters: HCHV contract beds and hotels or motel is paid for by charitable organizations or by federal, state and local government programs (TDCJ, HOPWA, etc.)
Institution stays of less than 90 days are considered a continuation of homelessness, if the client entered from a place not meant for human habitation, emergency shelter or save haven; if the institution stay is greater than 90 days, this constitutes a break in homelessness.
Have you been continuously homeless for a year or more?
*
HUD defines “homeless” as “a person sleeping in a place not meant for human habitation” e.g. living on the streets OR living in a homeless emergency shelter.
No
Yes
Describe homelessness over the past 12 months. Include all dates and locations (i.e. [month/year] to [month/year] at [location]):
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In the last three (3) years, have you been literally homeless on four (4) or more separate occasions, which total at least 12 months?*
*
HUD defines “homelessness” as “sleeping in a place not meant for human habitation” e.g. living on the streets OR living in a homeless emergency shelter.
No
Yes
Document all episodes of homelessness in the last three (3) years. Add one episode per line.
*
Add
Remove
Sum of Homeless Occassions (in months)
*
Documentation
Part III is supported by Third Party Certification, which includes dates and locations of homelessness, from one or more of the following documents. Upload all that apply.
Certification letter(s) from an emergency shelter for the homeless.
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.
Certification letter(s) from any other health or human service provider.
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.
Certification letter(s) from a homeless service provider or outreach worker.
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.
Certification
*
By adding my digital signature below, I certify that the information presented in this application is true to the best of my knowledge. I understand that false or misleading information may result in termination of housing.
Digital Signature
*
IMPORTANT!
Meeting the qualifications of this form does not complete the process for applying to Eden Village. The next step in the process is to complete the Application Form.
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