LAHSA Form 6053 is the standard homelessness verification form used across every homeless assistance program in the Los Angeles Continuum of Care. A qualified third party fills it out — or in limited cases the applicant self-certifies — to create the official record that housing programs rely on when checking eligibility. The current version has been effective since February 2024, and it’s a free two-page PDF.
Where To Download Form 6053
The form lives in the LAHSA document library at lahsa.org/documents. Search “6053” and the two-page PDF comes up.
Service providers working inside the Homeless Management Information System (HMIS) can also pull the form through that portal. If you’re the applicant, ask your case manager, outreach worker, or shelter staff for a blank copy. They use this form constantly and almost always have some on hand.
Who Can Sign the Form
Not just anyone can verify homelessness. HUD ranks documentation by reliability, and third-party verification sits at the top of that hierarchy. The form’s header collects the name of the person completing it, their agency, and their email and phone number.
Qualified third parties recognized under HUD recordkeeping rules include:
- Emergency shelter or safe haven staff who can confirm the household participated in their program during specific periods.
- Street outreach workers who directly observed the person sleeping unsheltered or saw signs of encampment.
- Nonprofit or government agency representatives who can confirm their agency paid for at least 51 percent of a hotel or motel stay for the household.
- Intake workers and case managers who, using professional judgment, found the household’s account of their living situation truthful.
- Community members who physically observed where the person was living. This verification also requires a written referral from another housing or service provider.
There’s also a field for someone relaying an oral statement. If the account comes from a person who isn’t the one signing the form, that person’s name goes in a separate header field.
How To Complete Each Section
For Continuum of Care Program eligibility, Sections 1, 2, and 3A all must be completed.
Header Information
Fill in the name of the person completing the form, agency (if applicable), email, phone number, and the applicant’s name. Enter the applicant’s HMIS or VSP identification number. If the verification is based on an oral statement, put the name of the person who provided that account in the designated field.
Section 1: Description of Encounter or Observation
Pick one option that best describes how you know the applicant was homeless. Only one option per form. If you need to verify multiple periods that involve different locations or different types of evidence, fill out a separate Form 6053 for each.
The six options are:
- Household participated in an emergency shelter program during the listed periods.
- Household participated in a safe haven program.
- A nonprofit or government agency paid for at least 51 percent of a hotel or motel stay.
- Based on professional judgment, the household’s self-reported living situation appeared truthful.
- Direct observation of the person sleeping unsheltered or signs of encampment at a specific location.
- Self-certification by the applicant.
Section 2: Episodes of Homelessness
List every month, including the current one, when the applicant was homeless as described in Section 1. Each month needs a corresponding location number from the form’s location list, showing whether the person was in emergency shelter, a safe haven, on the street, in a vehicle, or another place not meant for habitation. At least one day of homelessness in a given month counts for that whole month.
Accuracy on dates matters more than anything else on the form. If the months listed conflict with what’s already in HMIS or with other documentation, the verification can get flagged for follow-up. For chronic homelessness, this timeline has to show either 12 continuous months or at least four separate episodes over three years totaling 12 months.
Section 3A: Current Homelessness
Enter the most recent date the person was known to be at the listed location, as a full MM/DD/YYYY date, along with the location type. If the form supports an active housing application, this date must fall within seven days of the application submission. Anything older will not be accepted.
When Self-Certification Is Allowed
Section 1 includes a self-certification option: the applicant writes that they personally experienced homelessness in the listed periods and locations. This is the lowest tier of documentation and carries strict limits.
Under HUD recordkeeping rules, self-certification can cover up to three of the required 12 months of homelessness for any household. At least 75 percent of the households a program serves in a year must have third-party documentation covering at least 9 of those 12 months. Only in rare cases, where a person has been unsheltered and out of contact for long stretches, can self-certification cover the full period, and even then it’s capped at 25 percent of all households a program serves.
The self-certification has to be written and signed by the applicant. It does not need to be notarized. The intake worker still has to independently document the applicant’s living situation and record every step taken to obtain higher-priority evidence first. LAHSA also requires an accompanying Agency Due Diligence Form 1446 for each month covered by self-certification.
If self-certification is the initial documentation for chronic homelessness, HUD recommends the provider keep trying to obtain third-party documentation within 180 days of enrollment.
Extra Rules for Chronic Homelessness
Form 6053 is often the paper trail behind a chronic homelessness determination, which unlocks Permanent Supportive Housing. Under 24 CFR 578.3, “chronically homeless” means a homeless individual with a disability who either lived in an emergency shelter, safe haven, or unsheltered location continuously for at least 12 months, or had at least four separate homeless episodes over the last three years totaling 12 months.
Each break between episodes must have been at least seven consecutive nights spent somewhere other than a shelter, safe haven, or unsheltered location. Stays in institutional settings like jails, hospitals, or treatment facilities that lasted fewer than 90 days do not count as breaks. Those days fold into the 12-month total, as long as the person was homeless immediately before entering the facility.
Because each separate episode and each break must be documented, more than one Form 6053 is often needed, one for each distinct period involving a different location or verification source. Breaks can be verified through the applicant’s own self-report without the percentage caps that apply to the homeless episodes themselves.
Disability verification is required alongside Form 6053 for chronic homelessness. HUD expects this from a professional licensed by their state to diagnose and treat the disability, such as a physician, psychiatrist, or licensed psychologist.
Documentation for Domestic Violence Survivors
People fleeing domestic violence, dating violence, sexual assault, or stalking fall under a separate HUD eligibility category (Category 4), and the documentation path is different. Contacting a prior housing provider or shelter for verification can be dangerous, so HUD provides Form HUD-5382, a self-certification form for victim status. The applicant certifies that they or a household member is a victim of domestic violence or related abuse and signs the form.
Housing providers cannot require documentation beyond what’s described in the accompanying Notice of Occupancy Rights (Form HUD-5380), and they must give applicants at least 14 business days to respond to a written request for this documentation. Form 6053 may still be used to verify the periods and locations of homelessness. The domestic violence self-certification handles the separate question of why the person left or cannot return to prior housing.
How To Submit the Completed Form
The main submission method is uploading a digital scan into the applicant’s HMIS profile. LAHSA publishes a training guide on its website for uploading documents in HMIS. When you upload, select the correct document category so the form is classified as a homelessness verification. Miscategorized uploads can effectively hide the document from housing navigators searching for eligible candidates.
The scan needs to be legible and must include both pages. Submitting the document creates a timestamp that establishes when the verification period begins for the applicant. If electronic access isn’t available, LAHSA protocols allow the form to go through encrypted email or standard mail to the appropriate administrative office. The mailing address varies by program, so contact your LAHSA program representative for the current one.
What Happens After You Submit
Once Form 6053 is uploaded, it feeds into the applicant’s profile in the Coordinated Entry System (CES), which is how Los Angeles matches homeless individuals and families with available housing. Housing providers review the verification against their program’s eligibility criteria. If the timeline shows gaps that conflict with other data in HMIS, the agency may follow up for clarification. These inquiries are especially common for high-intensity programs like Permanent Supportive Housing, where chronic homelessness documentation is scrutinized closely.
A valid, complete Form 6053 does not expire. The form itself states that the verification has no expiration date. But when it’s supporting a housing application, the most recent date in Section 3A still has to fall within seven days of submission, so an old form usually needs a fresh one alongside it.