Vermont Affidavit of Homeless Status
Official state formOther requestsFree downloadLast verified November 10, 2026
A person experiencing homelessness uses this affidavit to prove identity for a certified birth certificate copy. The applicant and a homeless services provider sign it. It goes to the Vital Records Office in Waterbury.
Who can use this form
- A person experiencing homelessness, as defined in 42 U.S.C. 11302.
- A homeless services provider who knows the person's status verifies it.
What to send with it
- The affidavit, signed by the applicant and a legal representative of the provider.
- Submit it with the Application for Certified Copy of Vermont Birth or Death Certificate.
Where to send it
- Mail to
- Vital Records Office Vermont Department of Health 280 State Drive Waterbury, VT 05671-8370
- State fee
- Not provided
- Typical processing
- Not provided
- Source
- Official government page