9.21.26 Update of VHRC Request for Extension of 70 Night Cap

Request for Extension of 70 Night Cap

Vermont Homelessness Response Continuum
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Name (Head of Household)

First NameLast Name
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Email Address
example@example.com
Name of Person and Organization submitting this request (only complete if you are filling submitting this request on behalf of the household):
Name of Housing Case Manager and Organization Assisting Client:
Please provide the following information: On what date are you prepared to leave the hotel?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The Department may grant extensions to the 70-day limit for the following households. Check all the boxes that apply to you and describe the documents you are providing to support your request:
If you selected Option 1, what documentation is being provided to support this request?
If you selected Option 2, what documentation is being provided to support this request?
If you selected Option 3, what documentation is being provided to support this request?
If you selected Option 4, what documentation is being provided to support this request?
A housing plan must be submitted with this request. The plan should detail the steps being taken towards permanent housing, including timelines for each actionable step.

We need supporting documentation and a housing plan to review your request. If this information is not provided, your request for additional nights cannot be approved.
File Upload

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