Hvrp Manual Sample Forms

ADVERTISEMENT

HVRP Manual Sample Forms
This a sample form and does not mean NVTAC or US DOL-VETS endorses this form as required, or as an approved form. This form was one of many that were
collected from service providers and is only intended to help program planners develop forms and tools that will serve the needs of their program.
HVRP Documenting Veteran and Homeless Status
Applicant Name: _____________________________ Application Date: __________________
Veteran Status
1. Did you serve less than 180 Days (or less than 6 months) active duty? Yes 
No 
Did you receive a Medical Discharge for a service-connected disability during basic training?
Yes 
No 
2. Do you have one of the following documents (attach a copy to this certification)?
 DD 214 (Long Form with narrative) Statement of Service Letter
 VA ID Card (assist to obtain DD 214 online or offer referral to the Regional Office to Request a
Statement of Service Letter)
3. Is your military discharge other than Honorable?
Yes 
No 
4. Did you serve in a combat zone (i.e. Boots on the ground)? Yes 
No 
5. During what Era did you serve? ____________________________________ (War Era or
Peace Time)
Homeless Status
1. Tonight I will sleep…
□
In an apartment, motel, or home that I must leave within 14 days because
□
I received an Eviction Notice from a Court
□
I don’t have any money to pay for a place to live
□
The person whose place I’m staying-at said I must leave
The name of this person is ____________________________________
Phone ___________________
Their address is
______________________________________________________________
2.
Yes 
No 
I am staying in a homeless shelter.
Name of shelter: _____________________________________ Phone:____________________
3. I have been continuously homeless living on the streets or in shelters for the past 365 days.
Yes 
No 
4. During the past three years I have been homeless at least 4 times, living on the streets or in
shelters.
Yes 
No 
5. I am fleeing or attempting to flee domestic violence and no place to go and have no
financial resources or support (answer only if safety is not jeopardized).
Yes 
No 
_______________________________________
____________________
HVRP Applicant
Date

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form 020746 - Hcra/hra Manual Claim Form Starbucks - Premera Blue Cross Form 020746 - Hcra/hra Manual Claim Form Starbucks - Premera Blue Cross Business
Sample Form For Limited Representation Agreement Sample Form For Limited Representation Agreement Business
Sample Form Of Counter-notification To Mls Property Information Network, Inc. Objecting To A Claim Of Infringement Of Copyright And The Disabling Or Removal Of Material From The Multiple Listing Service Sample Form Of Counter-notification To Mls Property Information Network, Inc. Objecting To A Claim Of Infringement Of Copyright And The Disabling Or Removal Of Material From The Multiple Listing Service Legal
Sample Form Construction Progress Reporting Survey Sample Form Construction Progress Reporting Survey Business
Sample Form For Performing A Simple Root Cause Analysis Of An Injury Or A Near Miss Event Sample Form For Performing A Simple Root Cause Analysis Of An Injury Or A Near Miss Event Business
Sample Form Of Final Arbitration Agreement Sample Form Of Final Arbitration Agreement Legal
Sample Form 592-b Sample Form 592-b Financial
Sample Form 56 Sample Form 56 Business
Sample Form 8863 - Education Credits (american Opportunity And Lifetime Learning Credits) - 2011 Sample Form 8863 - Education Credits (american Opportunity And Lifetime Learning Credits) - 2011 Financial
Sample Form Resolution Sample Form Resolution Business

Related Categories

Parent category: Legal
Download
Go
Page of 2