Client Information s2

SAN BUENAVENTURA/OXNARD VASH Program Referral Form PLEASE SELECT WHICH THE CITY WHICH VETERAN WANTS TO LIVE IN: O SAN BUENAVENTURA O OXNARD Date: Referred By (Case Manager):

Referral Agency/Program Name: Case Manager Phone and Email:

Client Information Name:

Date of Birth: Social Security Number:

Phone: Email:

HMIS Client ID #, if available:

This person served in the active military, naval, or air service, and was discharged or released under conditions other than dishonorable. Yes No If Yes, is the Veteran VA Healthcare eligible? Yes No Did Veteran serve during: OIF OEF OND Other: ______Is the Veteran required to register as a lifetime sex offender in any state? Yes No

Housing Status

Where does the applicant currently sleep? Meets Criteria for Chronically Homeless: Emergency shelter One or more of the following disabling conditions: Transitional shelter A substance abuse disorder (Specify: ______) If so, how long ______A serious mental Illness (Specify: ______) Place not meant for human habitation A developmental disability (Specify: ______) Hospital, emergency room, or jail A chronic physical illness or disability, including the co- If so, how long? ______occurrence of two or more of these conditions (Specify: ______) If so, name facility: ______AND Other: ______Homeless continuously for a year or more, or Have had four (4) episodes of homelessness in the last three (3) year Are special accommodations needed to determine eligibility? No Yes: If Yes, Explain: ______(i.e. meet with Veteran at shelter, hospital, Veteran needs transportation, etc.) ______Is the client currently connected to or open to case management participation? Yes No

Household Composition (Attach additional sheets if necessary) Name Relationship to Client Gender Date of Birth Financial Information

Currently receiving benefits and/or services? Yes No Currently employed? Yes No

To certify the applying household meets the income requirements, please enter all household income in the chart below: Total Annual Household Member Source of Verification Source of Income Pay Interval Income

Total Income

To determine if the household meets the AMI requirement, locate the total number of household members in the top row and follow the column down to see if the total household income falls below the Area Median Income. Please indicate if the household falls below 30%, 50%, or 80% AMI by circling the corresponding income limit box.

Total Household Members 1 2 3 4 5 6 7 8 80% Income Limit $50,750 $58,000 $65,250 $72,500 $78,300 $84,100 $89,900 $95,700 50% Income Limit $31,750 $36,250 $40,800 $45,300 $48,950 $52,550 $56,200 $59,800 30% Income Limit $19,050 $21,800 $24,500 $27,200 $29,400 $32,570 $36,730 $40,890 Source: HUD FY 2015 Income Limits for Ventura County

How much money does the Veteran currently have saved or can he/she expect to save towards move-in costs? $ ______Note: Please attach copies of required documentation for all income sources, directly after this certification. Other relevant information:

Attachments, if available:  ID and Social  Proof of stated income  DD214 Printout  Bank Statements  Proof of homelessness

Would you like to be involved in the coordination of Veteran’s care after VASH referral is received? Yes No

Please email all SAN BUENAVENTURA referrals and attachments to [email protected] (805-698-

HUD-VASH Program 2 of 3 Program Referral Form / Rev. 11/17/2014 Please email all OXNARD referrals and attachments to [email protected] (310-497-3327)

HUD-VASH Program 3 of 3 Program Referral Form / Rev. 11/17/2014