VA SSVF Client Service Record v.1 (10-1-2014)

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Client ID:______

Service Date: ______

Type of Service:

Outreach Services

Case Management

Assistance in Obtaining VA Benefits

VA SSVF Client Service Record v.1 (10-1-2014)

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  • VA Vocational and Rehabilitation Counseling
  • Employment and Training Assistance
  • Education Assistance
  • Health Care Services

VA SSVF Client Service Record v.1 (10-1-2014)

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Assistance in Obtaining or Coordinating Other Public Benefits

VA SSVF Client Service Record v.1 (10-1-2014)

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  • Health Care Services
  • Daily Living Services
  • Personal Financial Planning Services
  • Transportation Services
  • Income Support Services
  • Fiduciary and Representative Support Services
  • Legal Services – Child Support
  • Legal Services – Eviction Prevention
  • Legal Services – Outstanding Fines and Penalties
  • Legal Services – Restore/Acquire Driver’s License
  • Legal Services – Other
  • Child Care
  • Housing Counseling

VA SSVF Client Service Record v.1 (10-1-2014)

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Direct Provision of Other Public Benefits

VA SSVF Client Service Record v.1 (10-1-2014)

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  • Personal Financial Planning Services
  • Transportation Services
  • Income Support Services
  • Fiduciary and Representative Support Services
  • Legal Services – Child Support
  • Legal Services – Eviction Prevention
  • Legal Services – Outstanding Fines and Penalties
  • Legal Services – Restore/Acquire Driver’s License
  • Legal Services – Other
  • Child Care
  • Housing Counseling

VA SSVF Client Service Record v.1 (10-1-2014)

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Other (non-TFA) Supportive Services Approved by VA

Financial Assistance Type

Rental Assistance

Utility Fee Payment Assistance

Security Deposit

Utility Deposit

Moving Cost

Transportation Services – tokens/vouchers

Transportation Services – vehicle repair/maintenance

Child Care

General Housing Stability Assistance – emergency supplies

General Housing Stability – other

Emergency Housing Assistance

Services Provided

Type of Service (general) / Specific Service Type / Service Description / Service Code
Outreach Services / Outreach Programs / TJ-6500.6300
Case Management / PH-1000
Assistance Obtaining VA Benefits / VA Vocational and Rehabilitation Counseling / Veteran Employment Programs / ND-6500.9200
Employment and Training Assistance / Employment / ND and related
Education Assistance / Education / H and related
Health Care Services / Health Care / L and related
Assistance Obtaining/Coordinating Other Public Benefits / Health Care Services / Health Care / L and related
Daily Living Services / Life Skills Education / PH-6200.4600
Personal Financial Planning Services / Personal Financial Counseling / DM-6500
Transportation Services / BT and related
Income Support Services / Income Support / N
Fiduciary and Representative Support Services / Representative Payee Services / DM-7000
Legal Services – Child Support / Child Support Assistance / FT-3000.1600
Legal Services – Eviction Prevention / Eviction Prevention Assistance / FT-4500.1800
Legal Services – Outstanding Fines and Penalties / Criminal and Civil Fine Collection Office / FJ-1715 and related
Legal Services – Restore/Acquire Driver’s License / Driver License Reinstatement Assistance/Driver Licenses / FT-9100.1800/DF-7000.1850
Legal Services – Other / Other / Varies
Child Care / Child Care Providers / PH-1250
Housing Counseling / BH-3700
Direct Provision of Other Public Benefits / Personal Financial Planning Services / Personal Financial Counseling / DM-6500
Transportation Services / BT and related
Income Support Services / Income Support / N
Fiduciary and Representative Support Services / Representative Payee Services / DM-7000
Legal Services – Child Support / Child Support Assistance / FT-3000.1600
Legal Services – Eviction Prevention / Eviction Prevention Assistance / FT-4500.1800
Legal Services – Outstanding Fines and Penalties / Criminal and Civil Fine Collection Office / FJ-1715 and related
Legal Services – Restore/Acquire Driver’s License / Driver License Reinstatement Assistance/Driver Licenses / FT-9100.1800/DF-7000.1850
Legal Services – Other / Other / Varies
Child Care / Child Care Providers / PH-1250
Housing Counseling / BH-3700
Other (non-TFA) Supportive Service Approved by VA / N/A / Supportive Non-Financial Assistance / Varies

Financial Assistance Provided

Type of Financial Assistance (general) / Description / Service Code
Rental Assistance / Rent Payment Assistance / BH-3800.7000
Utility Fee Payment Assistance / Utility Assistance / BV-8900
Utility Service Payment Assistance / BV-8900.9300
Security Deposit / Rental Deposit Assistance / BH-3800.7250
Utility Deposit / Utility Deposit Assistance / BV-8900.9150
Moving Cost / Moving Assistance / BH-5000 and related
Transportation Services – tokens/vouchers / Transportation Expense Assistance / BT-8300 and related
Transportation Services – vehicle repair/maintenance / Automotive Repair / BM-7000.0500 and related
Child Care / Child Care Expense Assistance / NL-3000.1500
Child Care Providers / PH-1250
General Housing Stability Assistance – emergency supplies / Material Goods / BM and related
Emergency Food / BD-1800 and related
Prescription Expense Assistance / LH-5100.6500
General Housing Stability Assistance – other / Other assistance allowable in the SSVF program guide
Emergency Housing Assistance / Homeless Financial Assistance Programs / NL-1000.3000