Request for Extension of 70 Night Cap
Vermont Homelessness Response Continuum
Date
-
Month
-
Day
Year
Date
Client Name (Head of Household)
*
First Name
Last Name
Client Email Address
example@example.com
Client Date of Birth
*
/
Month
/
Day
Year
Date
Name of Person submitting this request:
*
Name Organization submitting this request (put NA if you are the client and not part of an organization):
*
Name of Case Manager (put NA if there is no case manager):
*
Name of Case Manager's Organization (put NA if there is no case manager):
*
What date will the 70th night of housing be reached?
*
/
Month
/
Day
Year
Date
How many additional nights of housing are being requested?
*
What is the reason for the extension request?
*
How will the additional nights of housing assist you in achieving your housing goals?
*
Please check the documents included with this request
*
Housing Plan (required)
Documentation of progress towards housing goals (including plans to stay with family, friends, etc.).
Pending applications for subsidies or apartments
Other
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