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Screening Form Veterans Program Bill McKeown WIP

 

  • COC: Raleigh/Wake County

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Must be either client or another adult in household
  • Branch of Service

  • SSVF Eligibility:

    • Category 1 - Permanent housing at risk of losing their housing and becoming literally or remaining literally homeless.
    • Category 2 - Rapid Rehousing Homeless and scheduled to become a resident of permanent housing within 90 days pending the location or development of suitable permanent housing
    • Category 3 - Rapid Rehousing participant exiting from permanent housing in the last 90 days to seek other housing responsive to the Veterans family’s needs and preferences.   
  • Current Homeless Status:

  • [Prevention Clients-Skip if client is literally homeless]

  • Priority Risk Factors [Answer for all applicants]

  • Secondary Risk Factors [Answer for all applicants]

  • MM slash DD slash YYYY
  • Family Composition:

  • Income:

  • Check HUD Current Income Limits for family size to determine if client is at or below AMI.

  • I certify financial information is accurate and complete and that client is homeless or at risk of becoming homeless. I certify having no personal relationship between me or the client with the agency, community or HUD.

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