Veterans Forward: Homeless Assistance

Homeless Veterans Reintegration Program (HVRP) Eligibility Form
Veteran Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Veteran Birth Date

MonthDayYear
Date
Referred by Name
For example, if you're working with a case manager, enter their name here.
Referred by Organization
For example, if you're working with a case manager, enter their organization name here.
Referred by Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address or General Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the veteran have at least one day of active duty?
Does the veteran have a discharge status other than Dishonorable?
Does the veteran have a copy of their DD-214?
If a copy of the DD-214 is not available, was a copy requested?
Date of Request

MonthDayYear
Date
Verification of veteran status through SQUARES?
Homelessness Status
This is to certify that the above-named individual is currently homeless or was homeless in the last 60 days based on the check mark, other indicated information, and signature indicating their current living situation. Check only one box and complete only that section. Include supporting documents (Verification and Point of Contact).
Description of supporting verification to support the above selection. Include program, motel, hotel, shelter, or other relevant names. Attach supporting documents at the end of the application form.
Other Eligible Veterans (Participating in Partner Services)
This is to certify the at the above-named individual, although not homeless, meets one of the other criteria for HVRP eligibility. Check only one box and complete only that section. Include supporting documents.
At Risk of Homelessness
This is to certify that the above-named individual is at risk of homelessness in the next 60 days, has no subsequent residence identified, and lacks the resource to obtain housing.
Description of Risk Factors:
Describe why the veteran is at risk of homelessness.
Eligibility Determination

This will be completed after review by Veterans Forward staff.
Is the applicant eligible for HVRP?
Will the applicant be enrolled in HVRP?
If NO, describe why.
Upload supporting verification here.

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Veteran Signature

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Homeless Veterans Reintegration Program (HVRP) Eligibility Form

Homelessness Status

Other Eligible Veterans (Participating in Partner Services)

At Risk of Homelessness

Eligibility Determination