Date: _______________________

I ____________________________________________ declare that my family lacks a fixed, regular, and adequate nighttime residence, as defined by the following:   

o	Sharing the housing of other persons due to loss of housing, economic hardship or similar reason
o	Living in motels, hotels, campgrounds due to the lack of alternative adequate accommodations
o	Living in Emergency or Transitional Shelters
o	Having a nighttime residence that is a public or private place not ordinarily used for sleeping accommodations for people
o	Living in cars, parks, public spaces, abandoned buildings, substandard housing (lacking plumbing and/or lack of a functional kitchen), bus or train station or similar settings 

Signed: ___________________________________________________

Printed: ___________________________________________________

Witness: __________________________________________________

Engaged communities.  Empowered families.  School-ready kids.  www.promiseearlyeducation.org