HUD-VASH Exit Information [HUD-VASH only] Case Management Exit Reason Accomplished goals and/or obtained services Transferred to another HUD-VASH ○ ○ and no longer need CM program site Found/chose other Housing Did not comply with HUD-VASH CM ○ ○ Eviction and/or other Housing related issues Unhappy with HUD-VASH housing ○ ○ No longer financially eligible for HUD-VASH No longer interested in participating in ○ ○ Voucher this program Veteran cannot be located Veteran too ill to participate at this time ○ ○ Veteran is incarcerated Veteran is deceased ○ ○ Other (specify)_______________________ ○ CONTACT INFORMATION [Optional- can be entered in Location Tab] Phone Number Email Current Address (if applicable) Street City State Zip Code Signature of applicant stating all information is true and correct Date
HUD-VASH Exit Information [HUD-VASH only] Case Management Exit Reason ○ Accomplished goals and/or obtained services and no longer need CM ○ Transferred to another HUD-VASH program site ○ Found/chose other Housing ○ Did not comply with HUD-VASH CM ○ Eviction and/or other Housing related issues ○ Unhappy with HUD-VASH housing ○ No longer financially eligible for HUD-VASH Voucher ○ No longer interested in participating in this program ○ Veteran cannot be located ○ Veteran too ill to participate at this time ○ Veteran is incarcerated ○ Veteran is deceased ○ Other (specify)_______________________ CONTACT INFORMATION [Optional- can be entered in Location Tab] Phone Number Email Current Address (if applicable) Street City State Zip Code Signature of applicant stating all information is true and correct Date
VA-Combined-Project-Exit-HMIS-2017-rev07May2018.docx