D.10 Request Extension Form.pdf
PDF 130 KB Posted
- Solicitation number
- 36C25525R0011
About this file
This is a VA CRS (Community Residential Services) Extension Request Form used to request extensions for veteran housing services. The form must be submitted to the VA CERS Liaison 7 days before the end of a previous referral period or when requested by the CERS Liaison.
The form requires key information including the veteran's information, bed days used, contract case manager details, housing goals, progress toward those goals, and justification for the extension request. The bottom portion is reserved for COR (Contracting Officer's Representative) use only, where they can approve or deny the request, note the date processed, and add comments. The form is part of the Healthcare for Homeless Veterans (HCHV) Contract Emergency Residential Services (CERS) program at the VA Eastern Kansas Health Care System, supporting both the Dwight D. Eisenhower VA Medical Center and Colmery O'Neil VA Medical Center.
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Text version
VA CRS Extension Request Form
Complete form and email to VA CERS Liaison 7 days prior to the end of previous referral or if requested by CERS Liaison.
Veteran: Bed Days:
Contract Case Manager:
Housing goals:
Progress toward housing goals:
Justification for extension:
COR use only below this line
Date of Request:
Projected discharge date: Referrals:
Approved: Denied: Date processed:
Comments:
Contract CM Signature:
File details come from the government source that posted it. Updated .