VET360 Assistance Form

This form is used to identify veterans seeking assistance. It is important that the Veteran Services Commission should know who are these protected veterans in need for assistance. In this way, they can receive special assistance and benefits or qualify for certain programs offered by our referral partners. Please take note that this submission is voluntary. If you wish not to be identified, then you have the right to refuse to complete this document. This document is for: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. The data submitted from this form will be considered strictly confidential.

Please select what qualification of veteran you belongs to:

Disabled veteran Recently separated veteran Active wartime veteran Armed forces service medal veteran Other protected veteran I refused to identify Widow of Veteran Spouse of Veterans

Full Name

First Name Last Name

Veterans Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Best Contact Phone Number

Area Code Phone Number

Area of Assistance

HMIS#

If Known, Home Management Information System Number

Gender

Male Female Prefer Not to Say

Age

Date of Birth

Date

Ethnicity/Race

Number of Years in the Military

Current Living Status

Do you have any source of income?

Yes No

If yes, Source of Income Amount

Is Veteran Employed:

Yes No

Do you veteran have any mental health issues?

Yes No

Do you have any substance abuse issues?

Yes No

Again, filling up this form is voluntary. Also, your information will be strictly confidential.

Any Comments

Any information about your status you would like to share

Signature

Clear

Date Signed

Date