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CEDD SSVF Referral Form
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Comprehensive Eviction Defense and Diversion (CEDD): Supportive Services for Veteran Families (SSVF) Referral Form
Request Date
*
Date
form field Request Date
must be in the format: MM/dd/yyyy
CEDD Provider Information
Agency
*
Value is not selected
-- Select one --
Family Promise of Southwest New Jersey
Justice Innovation
Family Promise of Warren
The Waterfront Project
Homefront
Garden State Home
Catholic Family and Community Services
Community Affairs and Resource Center
Family Promise of Sussex
Jewish Family Services
Camden Coalition
New Jersey Association on Corrections
Volunteer Lawyers for Justice
Community Health Law Project
VolunteerUp
Staff First Name
*
Staff Last Name
*
Staff Title
*
Staff Email
*
Email
form field Staff Email
is not in correct form
Staff Phone Number
*
Phone
form field Staff Phone Number
must be in the format: (000) 000-0000
Veteran Information
First Name
*
Last Name
*
Date of Birth
*
Date
form field Date of Birth
must be in the format: MM/dd/yyyy
Social Security Number
SSN
form field Social Security Number
must be in the format: 000-00-0000
Gender
*
Woman (Girl, if child)
Man (Boy, if child)
Culturally Specific Identity (e.g., Two-Spirit)
Transgender
Non-Binary
Questioning
Different Identity
Client doesn't know
Client prefers not to answer
Data not collected
Email
*
Email
form field Email
is not in correct form
Phone Number
*
Phone
form field Phone Number
must be in the format: (000) 000-0000
HMIS (Homeless Management Information System) 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
*
Verification of Veteran Status (DD214 or statement that the Veteran is eligible for services along with a VISTA printout)
Form field Verification of Veteran Status (DD214 or statement that the Veteran is eligible for services along with a VISTA printout) has
Invalid files.
Household Composition
Additional Household Members
Add Household Member
Remove Household Member
Housing Status
Where does the applicant currently sleep?
*
Owned by client, no housing subsidy
Owned by client, with housing subsidy
Permanent housing for formerly homeless persons (e.g., SHP, S+C, SRO)
Rental by client, no housing subsidy
Rental by client, with VASH housing subsidy
Rental by client, with other (non-VASH) housing subsidy
Staying or living in a family member's room, apartment, or house
Staying or living in a friend's room, apartment, or house
Shared housing, with housing subsidy
Shared housing, no housing subsidy
Emergency shelter, including hotel or motel paid for with emergency shelter voucher
Hospital (non-psychiatric)
Hotel or motel paid for without emergency shelter voucher
Jail, prison, or juvenile detention facility
Place not meant for human habitation inclusive of 'non-housing service site (outreach program only)'
Psychiatric hospital or other psychiatric facility
Safe Haven
Substance abuse treatment facility
Transitional housing
Shelter Program/Motel Name
*
Please describe the applicant's current housing situation
Current Address:
Address Prepopulation
Enter the address to populate the following fields.
Address
Address line 2
City
State
ZIP code
County
*
Value is not selected
-- Select one --
ATLANTIC
BERGEN
BURLINGTON
CAMDEN
CAPE MAY
CUMBERLAND
ESSEX
GLOUCESTER
HUDSON
HUNTERDON
MERCER
MIDDLESEX
MONMOUTH
MORRIS
OCEAN
PASSAIC
SALEM
SOMERSET
SUSSEX
UNION
WARREN
Veterans Multi-Service Center
Email
form field Veterans Multi-Service Center
is not in correct form
Soldier On
Email
form field Soldier On
is not in correct form
Community Hope, Inc.
Email
form field Community Hope, Inc.
is not in correct form
Catholic Charities Dioceses of Camden, Inc.
Email
form field Catholic Charities Dioceses of Camden, Inc.
is not in correct form
Catholic Charities of Paterson: Catholic Family & Community Services
Email
form field Catholic Charities of Paterson: Catholic Family & Community Services
is not in correct form
Secondary Emails
Email
form field Secondary Emails
is not in correct form
Length of Stay/ How long lived at this address (days)
Form field Length of Stay/ How long lived at this address (days) has
Invalid numeric value.
Has the household received any of the following within the past 30 days?
3-Day Notice
3-Day Notice Date
Date
form field 3-Day Notice Date
must be in the format: MM/dd/yyyy
Eviction
Eviction Date
Date
form field Eviction Date
must be in the format: MM/dd/yyyy
Unlawful Detainer
Unlawful Detainer Date
Date
form field Unlawful Detainer Date
must be in the format: MM/dd/yyyy
Foreclosure
Foreclosure Date
Date
form field Foreclosure Date
must be in the format: MM/dd/yyyy
Eviction notice/ three day pay or quit notice, if seeking arrears assistance
Form field Eviction notice/ three day pay or quit notice, if seeking arrears assistance has
Invalid files.
Financial Information
Previously applied for and/or received SSVF assistance?
*
Yes
No
Not Sure
Currently receiving VA benefits and/or services?
*
Yes
No
Not Sure
Currently employed?
*
Yes
No
Monthly Income
Add Income Source
Remove Income Source
Other relevant information
Email Address:
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