AEL-Self-Attestation-Form Name* First Middle Last DATE OF BIRTH* MM DD YYYY Social Security Number* LOCAL PHONE NUMBEREmail* Purpose: To determine whether an individual who is 17 or 18 years of age and who cannot obtain a parent’s or guardian’s permission meets the criteria for receiving a qualified exemption under TEC 25.086Form 1: To determine whether an AEL services candidate is already attending secondary schoolAre you attending school? Yes No If YES, name of school If NO, what is the last date that you attended school? MM slash DD slash YYYY Are you enrolled in public school for next semester? YES No I, verify that the information I have provided is true and correct.Signature*Date* MM slash DD slash YYYY Form 2: To determine whether an AEL services candidate is living with a parent:Do you live in a home that your parent owns or rents? (Note: If yes, parental permission is required) Yes No Where do you usually sleep at night? (street address, apartment number, city, Zip code) Address Apartment # City ZIP Code How long have you been at that address?Year(s)Month(s)Day(s)Do you pay or receive bills in your name? Yes No What bills do you pay or receive? Please list: To what address are the bills delivered? Address City State / Province / Region ZIP / Postal Code What is your parents or guardians address, if different from where you sleep at night? Address City State / Province / Region ZIP / Postal Code When was the last time you slept at your parent’s or guardian’s address? Form 3: To determine whether an AEL services candidate is homeless as defined in 42 USC §11302Do you live in a place that has no windows, doors, running water, heat, or electricity? Yes No Are you living in a place that is overcrowded? Yes No Are you staying with a friend or relative because of a loss of housing or economic hardship, or for a similar reason? Yes No (Examples include eviction, foreclosure, fire, flood, divorce, domestic violence, the loss of a job, being told to leave by your parent, and running away from home.)Are you living in a shelter? Yes No (Examples include a family shelter, a domestic violence shelter, a shelter for children or youth, and housing funded by the Federal Emergency Management Agency.)Are you living in an unsheltered location? Yes No (Examples include living in a tent, in a vehicle, in an abandoned building, at a campground, in a park, and in a bus or train station.)Are you living in a hotel or motel because of a loss of housing or economic hardship? Yes No (Examples include eviction, foreclosure, flood, fire, hurricane, and lack of money to pay deposits for a permanent home.)Are you living in transitional housing? Yes No (that is, housing that is available as part of a program, is offered for a specific length of time only, and is partly or completely paid for by a church, a nonprofit organization, a governmental agency, or another type of organization)NameThis field is for validation purposes and should be left unchanged.
