COC: Raleigh/Wake CountyDate MM slash DD slash YYYY Completed by:Agency:Client Name First Last Client PhoneDOB MM slash DD slash YYYY SSN or last 4 digits:Client Email Have you ever served in the United States Military? Yes No Branch of ServiceBranch of ServiceDischarge Status: Honorable Dishonorable Other If “Other” explain:OEF/OIF/OND: Yes No DD-214: Yes No VASH Voucher: Yes No Housing Authority:Do you or have you received VA medical benefits or other VA benefits?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:County of Residence:Where did you sleep last night?Disabled: Yes No Mental Health Substance Abuse Physical Disability Client isLiterally homelessImminently losing housingUnstably housed & at risk of losing housing[Prevention Clients-Skip if client is literally homeless]Contract Rent Amount: $Past Due Amount $Which months delinquentCurrently monthly housing cost w/ utilities: $Actual or Pending Eviction Yes No If yes, date of eviction Month Day Year At risk of having utilities disconnected Yes No Late Notice: Yes No Utility Disconnect Notice: Yes No Living in condemned or substandard housing Yes No Over 50% of income spent on housing Yes No Recent death of spouse or primary care provider Yes No Priority Risk Factors [Answer for all applicants]Prior Eviction History Yes No Living in condemned or substandard housing Yes No Outstanding Utilities Yes No How much do you owe?Significant or Sudden loss of income Yes No Mental health condition that impacts housing Yes No DiagnosisDo you have a disability of long duration Yes No DiagnosisIs credit history currently affecting housing Yes No Lack of transportation that impacts employment Yes No Medical Crisis that impacts employment Yes No Any legal issues related to housing Yes No If yes, explain:Secondary Risk Factors [Answer for all applicants]Young HOH (under 25 w/children or pregnant) Yes No In the Past?Actual or Pending Foreclosure Yes No If yes, date of foreclosure Month Day Year Foreclosure or rental housing Yes No Temporarily doubled up due to housing crisis Yes No How long have you lived in your home (if prevention)? Or how long homeless?One week or lessMore than one week, but less than one monthOne to three monthsMore than three months but less than one yearOne year or moreHistory of being doubled up?First time1-2 times in the pastOne to three monthsChronic:4 in the past 3 monthsLong term: one year or moreHigh Amount of Medical Debt: Yes No In the past Family Composition:Number of Adults:Number of Children:Name, age and gender of all household members:Is there any expected change in family composition?Income:Do you currently have income: Yes No Is income permanent temporary Current EmployerHow long employed?Who’s Income?How long employed?Who’s Income?Other Income SourceMonthly AmountWho’s Income?Other Income SourceMonthly AmountWho’s Income?Non-cash benefits?Total Monthly Expenses:Check HUD Current Income Limits for family size to determine if client is at or below AMI.At or below 30% AMI Yes No At or below 50% AMI Yes No What Type of Assistance is Requested? Utility Rental Deposit Transportation Childcare Legal Benefits Employment Emergency Supplies Describe the need and reason for support:Are you currently receiving any financial resources from (family, donations, etc.)? Yes No ExplainDoes client lack family/support network: Yes No ExplainWithout this assistance would you be homeless: Yes No Are you currently receiving housing assistance from any other program: Yes No If yes, from where and for what services:Additional Information:I/We certify financial information is accurate and complete and that I/We are homeless/ at risk of becoming homeless. I/We certify having no personal relationship between me/us and the agency, community or HUD. Head of Household Signature:Date Month Day Year Other Adult in household signature:Date Month Day Year Case Manager Signature:Date Month Day Year
