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Housing and Urban Development-VA Supportive Housing (HUD-VASH) Referral Packet for Supportive Services for Veteran Families (SSVF) Temporary Financial Assistance (TFA)(For Rapid Rehousing Assistance ONLY)Contents TOC \o "1-3" \h \z \u Overview and Guidance PAGEREF _Toc459020747 \h 3Purpose of the Packet PAGEREF _Toc459020748 \h 3Eligibility for SSVF Assistance PAGEREF _Toc459020749 \h 3Eligibility Waiver Requests* PAGEREF _Toc459020750 \h 3Referral Process for HUD-VASH and SSVF PAGEREF _Toc459020751 \h 3Documentation Submissions and Expectations PAGEREF _Toc459020752 \h 4Check Requests PAGEREF _Toc459020753 \h 4Types of Eligible Assistance PAGEREF _Toc459020754 \h 4Documentation Checklist PAGEREF _Toc459020755 \h 5Supportive Services for Veteran Families (SSVF) Referral Form PAGEREF _Toc459020756 \h 6Basic Eligibility Verification Form PAGEREF _Toc459020757 \h 8Temporary Financial Assistance Request Form PAGEREF _Toc459020758 \h 9SSVF HUD-VASH Eligibility Waiver Form PAGEREF _Toc459020759 \h 10SSVF Client Participation Agreement PAGEREF _Toc459020760 \h 11SSVF Landlord Letter of Authorization PAGEREF _Toc459020761 \h 12Landlord Intent to Rent Agreement PAGEREF _Toc459020763 \h 13SSVF HMIS Data Supplemental Worksheet……………………………………………………………………………………………………………..……...15Overview and GuidancePurpose of the PacketThe Supportive Services for Veteran Families (SSVF) program provides supportive services and financial assistance to very low income Veterans and their families who are literally homeless or at risk of becoming literally homeless. SSVF's primary goal is to support Veterans who “but for” SSVF assistance will become or remain literally homeless.This referral packet should be used by Housing and Urban Development-VA Supportive Housing (HUD-VASH) staff when seeking SSVF Temporary Financial Assistance (TFA) for literally homeless Veteran households who would remain homeless "but for" SSVF assistance. Eligible TFA includes Security Deposits and Utility Deposits. This packet does NOT apply to Homelessness Prevention assistance.Of important note, SSVF grantees are not required to serve Veterans with HUD-VASH vouchers and will only do so at their discretion. HUD-VASH staff needs to pursue all other viable options prior to referring a Veteran household to SSVF for TFA assistance. HUD-VASH staff must clearly demonstrate that the Veteran household will remain literally homeless "but for" SSVF TFA assistance.Eligibility for SSVF AssistanceIn order to receive SSVF TFA, Veteran households in HUD-VASH must:Be chronically homeless (please see HUD's Chronic Homelessness Final Rule for more detail), meaning:Household lives in a place not meant for human habitation, safe haven, or in an emergency shelter (note: Veterans do NOT maintain chronic status once enrolled in community transitional housing; Veterans who were chronically homeless upon entry into Grant and Per Diem (GPD) programs do maintain their chronically homeless status);Household has been homeless continuously for at least 12 months or on at least four separate occasions in the last three years where the combined occasions must total at least 12 months; ANDHas a physical or mental disability that substantially limits one of more major life activities and has a record of such impairment or is regarded as having such impairmentHave a household income that does not exceed 30% of the local Area Medium Income (AMI). Current AMI Limits can be found here.The referral from HUD-VASH staff to SSVF grantees must be made PRIOR to a lease being signed. All other possible resources, including resources the Veteran household has, have been explored and "but for" SSVF TFA the household will remain literally homeless.Eligibility Waiver RequestsIn limited cases, a HUD-VASH case management teams may wish to request assistance for a Veteran whose status does not fall entirely within the specific eligibility criteria outlined in this document. Examples include Veteran households who are not chronically homeless or do not fall at or below 30 percent of AMI. On a case by case basis, SSVF grantees may use their discretion, in consultation with the HUD-VASH case management team, to discuss these circumstances. A specific Waiver Request Form must be completed and retained by the SSVF grantee.Referral Process for HUD-VASH and SSVFWhen a unit is identified (or prior to when a number of units are being considered), HUD-VASH staff should be prepared to submit the full SSVF HUD-VASH Referral Packet (“Packet”). The packet, or at a minimum the referral form included on page 6 of this document, must be submitted prior to the Veteran household signing a lease for the unit. This referral form establishes the required condition that the SSVF referral needs to be made prior to an executed lease.Documentation Submissions and ExpectationsIf the full packet is not in place, the referral will be placed on hold and priority will be given to completed packets. This may result in funding not being available.If only the referral form (page 6) is submitted at initial referral, the entire packet must be submitted before any TFA can be issued by the SSVF grantee. Once the full packet, including all documentation, is submitted:The SSVF grantee will notify the HUD-VASH staff of receipt of the packet within one business day.The SSVF grantee will review the packet and notify the HUD-VASH staff within two business days if any corrections or additional documentation is needed.The HUD-VASH staff will provide the missing documentation to the SSVF grantee within two business days of notification.Once all documentation is in place, a check request may be made based on the process describe below.Check RequestsUpon the referral documentation being complete and submitted:HUD-VASH staff will provide a copy of the signed lease and completed landlord W-9 Form, along with any other forms as required by the SSVF grantee.In the event that the landlord will not provide a copy of the signed lease, the Intent to Rent Form must be completed. The signed lease will still need to be submitted before a check can be provided to the landlord.Once a check is requested and all documentation is in place, the SSVF grantee will provide the check to the landlord or landlord agent within five working days. Letters guaranteeing checks can be provided to the landlord in the interim if required.Important: HUD-VASH staff should be clear with landlords that checks will not be delivered without a fully signed lease in place. The Intent to Rent Form can only initiate the check request but is not sufficient for the actual payment.Types of Eligible AssistanceSecurity Deposits, not to exceed value of two months' rentReasonable broker and application fees for the unit acquiredUtility Deposits or Current Charges DueUtility PaymentsGeneral Housing Stability AssistancePlease speak directly with the SSVF grantee to determine the types and amounts of assistance available in their specific grants. Note, SSVF grantees are NOT required to provide TFA to Veterans in HUD-VASH, but may do so at their discretion and if they determine that the needs of the Veteran warrant this co-enrollment with the HUD-VASH Program.Documentation ChecklistThis document MUST be submitted along with all supporting documentation to the SSVF grantee.Veteran Name (head of household): FORMTEXT ?????Last four of SSN: FORMTEXT ?????Other Family Member Names: FORMTEXT ?????Participant InformationCheck or Write N/A for item not applicable to specific Veteran request. FORMCHECKBOX SSVF HUD-VASH Referral Form (included in packet) FORMCHECKBOX SSVF Participant Agreement Form (included in packet) FORMCHECKBOX HMIS Release of Information (Form not included in packet - request from SSVF/CoC) FORMCHECKBOX Department of Veterans Affairs Request for and Authorization to release medical records (Form not included in packet – provided by VA) FORMCHECKBOX Application for Wavier of Requirement (if client is not chronically homeless or is over 30% AMI, HUD- VASH can submit a written request) FORMCHECKBOX Temporary Financial Assistance Request Form (included in packet) FORMCHECKBOX SSVF HMIS Data Supplemental Worksheet-Required (included in packet)Landlord Documentation (can be submitted after referral) for Security Deposits FORMCHECKBOX Copy of signed lease agreement (Intent to Rent Form can initiate the request but a full lease required to make payment.) FORMCHECKBOX W9 Form (Online download found here) FORMCHECKBOX SSVF Landlord Letter of Authorization (If the address/name for check request is different than what appears on the lease.)Other Unit Documentation (if applicable) FORMCHECKBOX Documentation of any broker or application fees FORMCHECKBOX Documentation details of required General Housing Stability Assistance (GSA) items (Note: please work directly with the SSVF grantees to determine the times of GSA, if any, available.)Documentation Required for Utility Deposit Assistance and Arrearages (Not all SSVF grantees provide Utility Assistance) FORMCHECKBOX Copy of utility bill stating security deposit charges FORMCHECKBOX Other supporting documentation as neededPlease explain any missing documentation and current efforts to secure that documentation, including anticipated timing. This information will help the SSVF grantee plan for check requests and process related to this unit.Supportive Services for Veteran Families (SSVF) Referral FormDate: FORMTEXT ?????Referred By (HUD-VASH Staff): FORMTEXT ?????Move in Date on Lease if known: FORMTEXT ????? Referring VAMC or CBOC: FORMTEXT ?????-381015938500 City, County where HUD-VASH Unit is Located: FORMTEXT ?????Staff Phone and Email: FORMTEXT ?????Amount of Financial Assistance Requested, if known: FORMTEXT ????? Alternate Staff Name and Email: FORMTEXT ?????Veteran InformationName: Phone: Email: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Household CompositionName (First, Middle, Last)Relation to VeteranSSNVet?(Y/N)GenderRace/EthnicityDisablingCondition (Y/N)Date of Birth FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Financial InformationPreviously applied for and/or received SSVF assistance? FORMCHECKBOX Yes FORMCHECKBOX NoCurrently receiving VA benefits and/or services? FORMCHECKBOX Yes FORMCHECKBOX NoCurrently employed? FORMCHECKBOX Yes FORMCHECKBOX NoEducationLast grade completed for any adults in the household that are not the head of household VeteranName: FORMTEXT ????? Last Grade Completed: FORMTEXT ?????Name: FORMTEXT ????? Last Grade Completed: FORMTEXT ?????Adults OnlyMonthly Income (A(AdulOnOnlWho: FORMTEXT ????? Source: FORMTEXT ?????Amount: $ FORMTEXT ?????Who: FORMTEXT ????? Source: FORMTEXT ?????Amount: $ FORMTEXT ?????Who: FORMTEXT ????? Source: FORMTEXT ?????Amount: $ FORMTEXT ?????Who: FORMTEXT ????? Source: FORMTEXT ?????Amount: $ FORMTEXT ?????Total Monthly Income: FORMTEXT ????? Total Annual Income: FORMTEXT ?????Non-Cash Benefits for Adults in Household who are not the Head of Household VeteranNon-Cash BenefitsWhoInformation Date: FORMTEXT ????? Non Cash Benefits from Any Source: FORMTEXT ????? If “Yes” FORMTEXT ????? Supplemental Nutrition Assistance Program (SNAP): FORMTEXT ????? Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): FORMTEXT ????? TANF Child Care services: FORMTEXT ????? TANF Transportation services: FORMTEXT ????? Other TANF-funded services: FORMTEXT ????? Section 8, public housing, or other ongoing rental assistance: FORMTEXT ????? Other source: FORMTEXT ????? Temporary rental assistance: FORMTEXT ????? If “Yes” for “Other Source” please specify the source FORMTEXT ????? Health Insurance for All Members of the Household (Excluding the Head of Household Veteran)Health Insurance:WhoInformation Date: FORMTEXT ????? Covered by Health Insurance: FORMTEXT ????? If “Yes” for “Covered by Health Insurance” Indicate all sources that apply FORMTEXT ????? MEDICAID: FORMTEXT ????? MEDICARE: FORMTEXT ????? State Children’s Health Insurance Program: FORMTEXT ????? Veteran’s Administration (VA) Medical Services: FORMTEXT ????? Employer – Provided Health Insurance: FORMTEXT ????? Health Insurance obtained through COBRA: FORMTEXT ????? Private Pay Health Insurance: FORMTEXT ????? State Health Insurance for Adults: FORMTEXT ????? Indian Health Services Program: FORMTEXT ????? Other: FORMTEXT ????? If “Yes” to “Other” please specify the source: FORMTEXT ????? Basic Eligibility Verification FormThis form should be used by HUD-VASH staff to confirm basic eligibility of a HUD-VASH Veteran for SSVF assistance. FORMCHECKBOX Yes, this individual is a Veteran eligible for SSVF assistance and has a discharge status of other than Dishonorable. FORMCHECKBOX Yes, this Veteran is currently chronically homeless or was chronically homeless at his/her entry into HUD-VASH.a. Has a physical or mental disability that substantially limits one or more major life activities; has a record of such an impairment; or is regarded as having such an impairmentb.Lives in a place not meant for human habitation, a safe haven, or in an emergency shelter; and has been homeless (as described above) continuously for at least 12 months or on at least 4 separate occasions in the last 3 years where the combined occasions must total at least 12 months occasions separated by a break of at least seven nights Stays in institution of fewer than 90 days does not constitute a break. FORMCHECKBOX Yes, this Veteran household has an annual income not exceeding 30% of AMI, as documented in the referral form and source income documents. FORMCHECKBOX Yes, this Veteran household will remain literally homeless "but for" SSVF TFA assistance and all other options and resources have been explored. Note SSVF grantees have the authority, and are strongly encouraged, to request additional information to verify that all other options and resources have been explored.Where is Veteran currently residing? FORMCHECKBOX Housing owned by Veteran (NOT eligible) FORMCHECKBOX Housing rented by Veteran (NOT eligible) FORMCHECKBOX Staying or living with family or friend (NOT eligible) FORMCHECKBOX Transitional housing program (Only eligible if GPD and chronic prior to entry) FORMCHECKBOX Residential treatment program (Only eligible if in less than 90 days and chronic prior to entry) FORMCHECKBOX Hospital (Only eligible if in less than 90 days and chronic prior to entry) FORMCHECKBOX Hotel or motel not paid by charitable organizations or by Federal, State or local government FORMCHECKBOX Hotel or motel paid by charitable organizations or by Federal, State or local government FORMCHECKBOX Emergency shelter FORMCHECKBOX Prison, jail (Only eligible if in less than 90 days and chronic prior to entry) FORMCHECKBOX Place not meant for habitation (outdoors, automobile, truck, boat) FORMCHECKBOX Other FORMTEXT ?????HUD-VASH Staff Name FORMTEXT ????? HUD-VASH Staff Signature FORMTEXT ?????Date of Form Completion FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Temporary Financial Assistance Request FormHousing Unit Assistance FORMCHECKBOX Security Deposit total amount requesting $ FORMTEXT ????? FORMCHECKBOX Broker’s Fee total amount requesting $ FORMTEXT ????? FORMCHECKBOX Application Fee Total amount requesting $ FORMTEXT ?????Utility Deposit Assistance FORMCHECKBOX Electric total amount requesting $ FORMTEXT ????? FORMCHECKBOX Gas total amount requesting $ FORMTEXT ????? FORMCHECKBOX Water total amount requesting $ FORMTEXT ?????Utility Payment Assistance FORMCHECKBOX Electric total amount requesting $ FORMTEXT ?????Number of Months Anticipated: FORMTEXT ????? FORMCHECKBOX Gas total amount requesting $ FORMTEXT ?????Number of Months Anticipated: FORMTEXT ????? FORMCHECKBOX Water total amount requesting $ FORMTEXT ????? Number of Months Anticipated:_ FORMTEXT ?????General Housing Stability Assistance (GSA) Needs (Call ahead to inquire about agency availability.)Furnishings/Basics NeedsI have first checked the availability of furniture that is provided by Veteran Service Organizations and any other free community resources prior to requesting SSVF furniture assistance. Basic Household Goods (please specify): FORMTEXT ????? Amount:_ FORMTEXT ?????Other (please specify): FORMTEXT ????? Amount: FORMTEXT ?????Mattress: Queen Quantity/cost FORMTEXT ?????Full Quantity/cost FORMTEXT ?????Twin Quantity/cost FORMTEXT ?????Total SSVF Temporary Financial Assistance Requested for Household: $ FORMTEXT ?????HUD-VASH Staff Verification: FORMTEXT ?????HUD-VASH Supervisor Verification: FORMTEXT ?????Date FORMTEXT ?????SSVF HUD-VASH Eligibility Waiver FormTo be filled out by the HUD-VASH staff and provided to the SSVF grantee representative, if applicable.Veteran Name: FORMTEXT ?????Veteran DOB: _ FORMTEXT ????? Last 4 SSN: FORMTEXT ?????HUD-VASH Staff Person Name: FORMTEXT ?????Staff Phone: FORMTEXT ?????Staff Email: FORMTEXT ?????I wish to apply for a waiver to the following requirements on behalf of the above-named Veteran: FORMCHECKBOX Veteran is not chronically homeless FORMCHECKBOX Veteran household income exceeds 30% of AMI Please explain the reasons for this waiver application: (Please type): FORMTEXT ?????For SSVF Internal Use OnlySSVF Reviewer: FORMCHECKBOX Request Approved FORMCHECKBOX Request DeniedReason for Approval/Denial:SSVF Supervisor Name: FORMTEXT ?????SSVF Supervisor Signature FORMTEXT ?????Date of Decision: FORMTEXT ?????SSVF Client Participation AgreementI, FORMTEXT ?????am applying for temporary benefits available through the Supportive Services for Veteran Families (“SSVF”) program. My signature below confirms the following:1. My participation in the SSVF Program is voluntary for me and my household.2. I understand that the information that I provide to the SSVF program must be complete and accurate to the best of my knowledge. I also understand that I have a continuing obligation to promptly supplement, complete, or correct such information – and that my failure to do so will be deemed to be a failure to cooperate that could result in my loss of benefits (including benefits that have already been paid to others on my behalf).3. I understand that the failure to provide additional requested documentation or inappropriate behavior towards SSVF staff could also result in my loss of benefits (including benefits that have already been paid to others on my behalf).4. I understand that I am not automatically entitled to benefits. My eligibility for SSVF benefits depends on a variety of factors, some of which are subjective and at the discretion of the SSVF staff.5. I understand that SSVF-funded programs provide temporary (short-term) assistance only and that the amount of any benefits awarded is governed by Department of Veteran Affairs (VA) regulations and also depend on my particular circumstances. I further understand that no permanent assistance is available from any SSVF Program under any circumstances.6. I understand that if I fail to cooperate with any SSVF program, or if I provide incomplete or inaccurate information that I may be disqualified from the SSVF Program and may be required to return funds that have been paid to others on my behalf.7. I have the right to obtain from the SSVF case manager, a copy of my file concerning my application for SSVF benefits. Additionally, I understand that I have the right to seek legal counsel (however, at no expense to the SSVF agency) and to have my legal counsel present at any meetings regarding this matter.Veteran Signature: FORMTEXT ?????HUD-VASH Staff Signature: FORMTEXT ?????Date: FORMTEXT ?????SSVF Landlord Letter of Authorization To be completed if address is different than listed on lease. Payee must match W-9.All SSVF financial assistance payments checks should be mailed to: (Payee name must match the W-9.)Payee Name: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? Zip: FORMTEXT ?????Phone: FORMTEXT ?????For property located:Address: FORMTEXT ?????City: FORMTEXT ?????Zip: FORMTEXT ?????OWNER (print name)Signatures FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Phone #: FORMTEXT ????? Date: FORMTEXT ?????Landlord Intent to Rent AgreementTo be completed only if a landlord will not provide copy of signed lease prior to SSVF assistance.The tenant, FORMTEXT ????? (Name of Tenant)intends to rent property located at: FORMTEXT ????? from FORMTEXT ????? (Name of Landlord), Landlord, and hereby enters into an agreement prior to the lease that will commence on FORMTEXT ????? and agrees that the security deposit for the amount of $ FORMTEXT ?????, will be paid prior to the tenant occupying the above property.PAYMENT TERMS: FORMTEXT ????? (Agency Name) agrees to make payment within five to seven business days from the date of receiving a signed lease agreement. FORMTEXT ????? (Agency Name) appreciates your partnership in assisting Veterans and their families and looks forward to continued collaboration. FORMTEXT ????? FORMTEXT ?????Landlord signature Date FORMTEXT ????? FORMTEXT ?????Tenant signature Date FORMTEXT ????? FORMTEXT ?????SSVF Program Staff signature Date SSVF HMIS Data Supplemental Worksheet (Veteran Receiving HUD-VASH)Please note that local HMIS Implementations may require additional information. Data ElementHOMES Data Entry Worksheet LocationResponsesVAMC Station Number:HUD-VASH Entry B/Homeless Assessment BClick or tap here to enter text.Name:HUD-VASH Entry D/Homeless Assessment Q1Click or tap here to enter text.Social Security Number:HUD-VASH Entry E/Homeless Assessment Q2Click or tap here to enter text.Date of Birth: HUD-VASH Entry F/Homeless Assessment Q3Click or tap here to enter text.Race:Homeless AssessmentQ7 Choose an item.Ethnicity:Homeless Assessment Q8Choose an item.Gender:Homeless Assessment Q4Choose an item.Veteran StatusLast Grade Completed:Last Grade Completed:Homeless Assessment Q11Choose an item.Project Type Applicability:SSVF EntersPH-Rapid Re-HousingType of Residence (Prior to Project Entry):Homeless Assessment Q20 Choose an item.Length of Stay in the prior living situation (Prior to Project Entry):Homeless Assessment Q21aChoose an item.Project Entry Date:SSVF EntersClick or tap to enter a date.Project Exit Date:SSVF EntersClick or tap to enter a date.Destination:SSVF EntersChoose an item.Last Permanent AddressStreet Address:Click or tap here to enter text.City:Click or tap here to enter text.State:Click or tap here to enter text.Zip Code:HUD-VASH Entry Q10/Homeless Assessment Q22 Click or tap here to enter text.Address Data Quality:Choose an item.Project Type Applicability:SSVF EntersChoose an item.Client Location (CoC of Current Residence): (Where Veteran is moving to)Choose an item.Income and Sources:Information Date:Click or tap to enter a date.Income from Any Source:Choose an item.If “Yes”: Please answer below. Earned Income: (i.e. Employment Income)Choose an item.Unemployment Insurance:Choose an item.Monthly Amount: Click or tap here to enter text.Supplemental Security Income:Choose an item.Monthly Amount: Click or tap here to enter text.Social Security Disability Income (SSDI):Choose an item.Monthly Amount: Click or tap here to enter text.VA Service-Connected Disability Pension:Choose an item.Monthly Amount: Click or tap here to enter text.Private Disability Insurance:Choose an item.Monthly Amount: Click or tap here to enter text.Worker’s Compensation:Choose an item.Monthly Amount: Click or tap here to enter text.Temporary Assistance for Needy Families (TANF):Choose an item.Monthly Amount: Click or tap here to enter text.General Assistance (GA):Choose an item.Monthly Amount: Click or tap here to enter text.Retirement Income from Social Security:Choose an item.Monthly Amount: Click or tap here to enter text.Pension or retirement income from a former job:Choose an item.Monthly Amount: Click or tap here to enter text.Child Support:Choose an item.Monthly Amount: Click or tap here to enter text.Alimony and other spousal support:Choose an item.Monthly Amount: Click or tap here to enter text.Other source:Choose an item.Monthly Amount: Click or tap here to enter text.If “Yes” for “Other Source” please specify the sourceClick or tap here to enter text.Total Monthly Amount:Monthly Amount: Click or tap here to enter text.Non-Cash BenefitsInformation Date:Click or tap to enter a date.Non Cash Benefits from Any Source:Choose an item.If “Yes”Supplemental Nutrition Assistance Program (SNAP):Choose an item.Special Supplemental Nutrition Program for Women, Infants, and Children (WIC):Choose an item.TANF Child Care services:Choose an item.TANF Transportation services:Choose an item.Other TANF-funded services:Choose an item.Section 8, public housing, or other ongoing rental assistance:Choose an item.Other source:Choose an item.Temporary rental assistance:Choose an item.If “Yes” for “Other Source” please specify the sourceClick or tap here to enter text.Health Insurance:Health InsuranceInformation Date:Click or tap to enter a date.Covered by Health Insurance:Choose an item.If “Yes” for “Covered by Health Insurance” Indicate all sources that applyMEDICAID:Choose an item.MEDICARE:Choose an item.State Children’s Health Insurance Program:Choose an item.Veteran’s Administration (VA) Medical Services:Choose an item.Employer – Provided Health Insurance:Choose an item.Health Insurance obtained through COBRA:Choose an item.Private Pay Health Insurance:Choose an item.State Health Insurance for Adults:Choose an item.Indian Health Services Program:Choose an item.Other:Choose an item.If “Yes” to “Other” please specify the source:Click or tap here to enter text.Services Provided – SSVFOptionalDate of Service: SSVF Enters if Other Service ProvidedClick or tap here to enter text.Type of Service:Choose an item.If “Assistance obtaining VA Benefits”:Choose an item.If “Assistance obtaining/coordinating other public benefits”Choose an item.If “Direct provision of public benefits”Legal services - child supportIf “Other (Non-TFA) Supportive Services approved by VA”Click or tap here to enter text.Financial Assistance – SSVFSSVF EntersDate of Financial Assistance:SSVF EntersClick or tap here to enter text.Financial Assistance Amount:SSVF EntersClick or tap here to enter text.Financial Assistance Type:SSVF EntersResidential Move-In Date:SSVF EntersClick or tap here to enter text.Percent of AMI (SSVF Eligibility)Household income as a Percentage of AMIChoose an item.Disabling ConditionChoose an item. ................
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