Homeless Veterans Reintegration Program (HVRP) Eligibility Form
Preview PDF
Print Form
Submit
Veteran Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Veteran Birth Date
*
-
Month
-
Day
Year
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.
Current Address or General Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the veteran have at least one day of active duty?
*
Yes
No
Does the veteran have a discharge status other than Dishonorable?
*
Yes
No
Does the veteran have a copy of their DD-214?
*
Yes
No
If a copy of the DD-214 is not available, was a copy requested?
*
Yes
No
N/A, DD-214 provided
Date of Request
/
Month
/
Day
Year
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).
Place not meant for human habitation: The person named above is/are currently living in a place not designed for regular, nighttime accommodation for human beings, including a car, park, abandoned building, bus station, airport, or campground, etc.
Emergency Shelter: The person named above is currently living in a shelter.
Transitional Housing: The person named above is currently in a transitional housing program for persons who are homeless, such as a Veteran GPD program.
Fleeing Domestic Violence: The person named above is currently fleeing or attempting to flee domestic violence with no place to go and no financial resources or support.
Living in Hotel Paid by Others: Living in a rented hotel or motel paid for by a charitable organization or government program. The person named above is living in a rented hotel or motel paid for by a charitable organization or government program, as evidenced by a motel receipt, and verification from the hotel/motel or organization/program.
Homeless in the Past 60 Days: Currently housed but was in a situation listed above in the last 60 days.
Imminent Risk of Homelessness within 14 Days: The person named above will imminently lose their primary nighttime residence within 14 days, as evidenced by an eviction notice (or other documentation) and lacks the resources or obtain new housing.
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.
Veteran Transitioning from Incarceration and/or Transitional Housing related to Incarceration: The person named above is exiting from incarceration within the next 12 months and at risk of homelessness, OR the person name above was released from incarceration within the last 12 months
Veteran participating in Partner Services: The person named above is participating in HUD-VASH, Tribal HUD-VASH, SSVF, or receiving assistance under the Native American Housing Assistance and Self Determination Act of 1996
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.
The person named above is at risk of homelessness in the next 60 days and lacks the resources 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?
Yes
No
Will the applicant be enrolled in HVRP?
Yes
No
If NO, describe why.
Upload supporting verification here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Veteran Signature
Preview PDF
Print Form
Submit
Should be Empty: