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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

Cell Phone

Work Phone

Part 1: A Disabling Condition

Do you have any disabilities?*

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?*

Yes

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.

Yes

Describe homelessness over the past 12 months. Include all dates and locations (i.e. [month/year] to [month/year] at [location]):*

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.

Yes

Document all episodes of homelessness in the last three (3) years. Add one episode per line.*

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

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

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

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.

Qualifying Disability & Homelessness Verification

Qualifying Disability and Homelessness Verification

Part 1: A Disabling Condition

Part II: Duration in Tulsa Metropolitan Area

Part III: Chronically Homeless Status

Documentation