STATE OF WISCONSIN, DEPARTMENT OF VETERANS AFFAIRS
201 West Washington Avenue, P.O. Box 7843, Madison, WI 53707-7843
(608) 266-1311 1-800-WIS-VETS (947-8387)
Wis. Stats. Chapter 45
APPLICATION FOR AMERICAN INDIAN VETERANS SERVICE GRANT
The information requested on this form is authorized for collection by Ch. 45, Wis. Stats. and VA 15, Wis. Adm. Code. The information collected is used to determine
eligibility for programs administered by the department. Completion of this form is voluntary; however, failure to furnish the requested information may result in
denial of eligibility for programs. Personally identifiable information collected on this form is not likely to be used for any other purpose.
This department does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in employment or provision of services.
Pursuant to Section. 45.82(4), Wisconsin Statutes,
Tribe, hereby applies
for an American Indian Veterans Service Grant for the Fiscal Year beginning
, and ending
July 1, 2015
, for the purpose of extending and strengthening service of veterans of this tribe.
June 30, 2016
Personnel now employed, with present and proposed monthly salary, by this tribe to operate the Tribal Veterans Service
Office (TVSO) are:
Job Title
Tribal Veterans Service Officer (TVSO)
Choose one:
Full-Time or
Part-time
Others: (Insert Tribal Job Title)
Salary
$
$
$
$
$
$
(List any added positions proposed for the office for the coming Fiscal Year, with salaries.)
The application is hereby agreed to by the Tribal Council of
include all of the following conditions:
Nation to
1. The TVSO shall be appointed in accordance with VA 15.03.
2. The Tribal Veterans Service Office will be maintained, open and staffed during normal tribal or band office hours; and
3. The grant received will not be allocated “for use by another tribal department nor may the tribe reduce funding to a
tribal veterans service office based upon receipt of a grant.” Grant funds shall be maintained in a separate account subject to
audit by Wisconsin Department of Veteran Affairs.
Tribal Veterans Service Officer
Tribal President/Chairperson
Or Designated Tribal Council Official
Please submit with this application a signed grant agreement (WDVA 0056C), federal benefit report (WDVA 0056D) and
statement in the application cover letter which addresses success in meeting the previous year goals and objectives and
include the goals and objectives for the current fiscal year (71/1/15 – 6/30/16).
WDVA 0056B (09/15)
W:\Templates\WDVA_0056B_TVSO_Grant_Application.dot
You can access the most recent version of this form
from the WDVA website at www.WisVets.com/Forms.
STATE OF WISCONSIN, DEPARTMENT OF VETERANS AFFAIRS
201 West Washington Avenue, P.O. Box 7843, Madison, WI 53707-7843
(608) 266-1311 1-800-WIS-VETS (947-8387)
Wis. Stats. Chapter 45
GRANT AGREEMENT
BETWEEN THE STATE OF WISCONSIN, DEPARTMENT OF VETERANS AFFAIRS
AND
TRIBAL VETERANS SERVICE OFFICER
This agreement is made and entered into effective this
day of
,
1st
July
2015
between the Department of Veterans Affairs (hereinafter referred to as the “Department”), the
Nation and the
Nation Tribal Veterans Service
Officer (hereinafter referred to as the TVSO).
,
The TVSO shall file a grant application with the Department of Veterans Affairs for the current fiscal year, which shall
include a federal benefits service delivery report for the preceding fiscal year (7/1/14 – 6/30/15).
The attached statement of goals and objects for July 1, 2015 through June 30, 2016 is a part of this agreement. The TVSO
agrees to provide the Department with relevant information pertaining to the achievement of those goals and objectives.
The provision of services to former military personnel, dependents and survivors covered by this agreement shall be from
through
.
July 1, 2015
June 30, 2016
The Department shall twice yearly reimburse the TVSO’s tribe for documented expenses subject to the statutory annual
reimbursement limit under Wis. Stats. s. 45.82(4) provided the TVSO and the TVSO’s tribe have abided by the terms and
conditions of this agreement.
STATE OF WISCONSIN
DEPARTMENT OF VETERANS AFFAIRS
NATION OF
STATE OF WISCONSIN
BY:
BY:
James Bond
Division Administrator
Division of Veterans Benefits
TVSO
WDVA 0056C (09/15)
W:\Templates\WDVA_0056C_TVSO_Grant_Agreement_Between_WDVA_and_TVSO.dot
You can access the most recent version of this form
from the WDVA website at www.WisVets.com/Forms.
STATE OF WISCONSIN, DEPARTMENT OF VETERANS AFFAIRS
201 West Washington Avenue, P.O. Box 7843, Madison, WI 53707-7843
(608) 266-1311 1-800-WIS-VETS (947-8387)
Wis. Stats. Chapter 45
AMERICAN INDIAN VETERANS SERVICE GRANT — FEDERAL BENEFITS REPORT
The information requested on this form is authorized for collection by Ch. 45, Wis. Stats. and VA 15, Wis. Adm. Code. The information collected is used to determine eligibility for programs
administered by the department. Completion of this form is voluntary; however, failure to furnish the requested information may result in denial of eligibility for programs. Personally
identifiable information collected on this form is not likely to be used for any other purpose.
This department does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in employment or provision of services.
REPORT FOR THE FISCAL YEAR
From
July 1, 2014
; FOR
2015
, to
TVSO
June 30, 2015
FEDERAL BENEFITS
ACTIVITY
1. Power of Attorney
Indicate the number of new VA
Form 21-22s submitted to WDVA/Other VSOs for
representation
NUMBER
COMMENTS
/
2. Disability Compensation
Indicate the number of
new VA Form 21-526s, reconsiderations VA 21-526 or 21-527
or other communications submitted for compensation benefits to
WDVA/VA or other VSO
3. Pension
Indicate the number of VA Form 21-527s or other
communications submitted for veterans Pension benefits to
WDVA/VA or other VSO
4. Medical Expenses for Pension
Indicate the
number of VA Form 21p-8416s submitted for Unreimbursed
Medical Expenses for pension and death pention to WDVA/VA
or other VSO
5. Loan Guaranty
Indicate the number of Federal Home
Loan applications submitted
6. Educational
Indicate the number of Federal Educational
benefit applications submitted
7. Vocational Rehabilitation
Indicate the number of
Federal VocRehab applications submitted
8. Medical
Indicate the number of VA Form 1010EZ forms
submitted for enrollment into VA Healthcare
9. USDVA Notices of Disagreement
Indicate the
number of Notice of Disagreements, VA Form 21-0958, DRO
Request forms submitted to WDVA/VA or other VSO
10. USDVA Waiver Requests
Indicate the number of
requests for waivers of Federal benefits regulations submitted
11. BVA Appeals
Indicate the number of VA Form 9s
submitted to WDVA/VA or other VSO
12. Insurance
Indicate the number of applications for VA
Insurance programs submitted
13. Burial Allowances
Indicate the number of applications
for VA Burial Allowance submitted
14. Flag Applications
Indicate the number of applications
submitted for Burial Flags
15. Marker Applications
Indicate the number of
applications submitted for Burial Markers
16. DIC
Indicate the number of applications for Dependency and
Indemnity Compensation, VA Form 21-534, submitted to
WDVA/VA or other VSO
17. Survivor’s Pension
Indicate the number of applications
for VA Death Pension, VA Form 21-534, submitted to
WDVA/VA or other VSO
18. Discharge Correction
Indicate the number of
applications for discharge upgrades submitted
19. Miscellaneous
Indicate the number of applications for
other federal benefits, not listed, submitted by your office.
Include types in comments.
WDVA 0056D (09/15)
W:\Templates\WDVA_0056D_TVSO_Grant_Federal_Benefits_Report.dot
You can access the most recent version of this form
from the WDVA website at www.WisVets.com/Forms.
STATE OF WISCONSIN, DEPARTMENT OF VETERANS AFFAIRS
201 West Washington Avenue, P.O. Box 7843, Madison, WI 53707-7843
(608) 266-1311 1-800-WIS-VETS (947-8387)
Wis. Stats. Chapter 45
TRIBAL VETERANS SERVICE REIMBURSEMENT GRANT WORKSHEET
Reimbursement Grant Period:
7/1/15 – 12/31/15
Reimbursement Grant Period
1/1/16 – 5/31/16
Tribal Nation:
Notice: Information requested on this form is required by the Department when applying for a reimbursement of eligible expenses.
The Department will not consider your payment request unless you complete and submit this form.
Instructions: Itemize all expenses and attach legible photocopies of proof of expenses and payments for each item listed. See reverse for instructions.
Use additional worksheets as necessary, numbering each.
Date Expense
Incurred
Invoice/Statement Proof of
#
Payment Type
and #
WDVA 0056F (09/15)
W:\Templates\WDVA_0056F_TVSO_Reimbursement_Grant_Worksheet.dot
Payee
Eligible Expense Description
Eligible Cost
of Expense
Amount
Requested for
Reimbursement
Total
$
$
You can access the most recent version of this form
from the WDVA website at www.WisVets.com/Forms.
INSTRUCTIONS FOR COMPLETING TRIBAL VETERANS SERVICE REIMBURSEMENT GRANT WORKSHEET
Use the worksheet to itemize all proposed eligible expenses.
• Attach legible photocopies of proof of expenses and payments for each item listed.
• Use additional worksheets as necessary.
• Submit Worksheet(s) and attachments to: WDVA, Division of Veterans Benefits, Grants Unit, 201 West Washington Avenue, Madison, WI
53703 or email to VetsBenefitsGrants@dva.wisconsin.gov.
Date Field and Column Definitions
Date Expense Incurred: Date of invoice, purchase, or service rendered.
• Costs incurred prior to the beginning date or after the ending date of the grant reimbursement period are not eligible for reimbursement.
Invoice/statement #: Number on vendor invoice or bill associated with the purchase or service.
• Combined Costs: If an invoice combines costs for multiple grants or expenses, identify and explain specific costs associated with each grant
expense. Attach a copy of this invoice, as well as proof of payment identified below. Use as many lines as necessary.
Proof of Payment type and #: Copy of a receipt, number on check or money order used to pay the expense. If no proof of payment number, leave
blank. Attachments required:
• Expenditure Proof of Payment Examples: Copy of receipt; canceled check, with front side of check containing the amount of the check
digitally printed by the bank under the signature line; Non-canceled check with bank statement showing check cleared account; payroll
vouchers; Credit card statements. For acquisition expenditures, acquisition closing statements.
• Combined Proofs of Payment: If a proof of payment covers multiple expenses or grants, identify payments related to the particular grant
expense on a copy.
Payee: Name of consultant, contractor, vendor, supplier, etc. to whom payment was made.
Eligible Expense Description: Describe expense briefly. Include only eligible expenses as specified in Wis. Stats. s. 45.82(5):
 Information technology.
 Transportation for veterans and service to veterans with barriers.
 Special outreach to veterans.
 Training and services provided by the department and the federal department of veterans affairs.
 Salary and fringe benefit expenses incurred in 2015; salary and fringe benefit expenses incurred in
2016, except that total reimbursement for such expenses shall not exceed 50 percent of the applicable maximum grant.
Eligible Cost of Expense: The cost of the expense paid by the Tribe or Band. Enter only actual expenditures in this column.
Amount Requested for Reimbursement: Requested reimbursement.
WDVA 0056F (09/15)
W:\Templates\WDVA_0056F_TVSO_Reimbursement_Grant_Worksheet.dot
You can access the most recent version of this form
from the WDVA website at www.WisVets.com/Forms.
I certify that the information provided in the Tribal Veterans Service Reimbursement Grant Worksheet for this grant is
accurate. Grant funds shall be maintained in a separate account subject to audit by the Wisconsin Department of Veterans
Affairs. I further agree to fully cooperate in any review and audit of grant expenditures by the department, including the
provision of any relevant single audit document that establishes that grant funds previously received have been audited. I
understand that pursuant to s. 45.47 Stats., if a county fails to comply with the above requirements, the Wisconsin
Department of Veterans Affairs may, in addition to any other legal remedy available, reduce, suspend, or terminate the
grant provided to the applicant.
The person signing below this line must be a designated Tribal Council Official, authorized to certify the completed Tribal
Veterans Service Reimbursement Grant Worksheet is complete and accurate.
Name:
Position:
Please print legibly
Phone Number:
(
Email:
)
Signature:
Date:
Reimbursement check should be made payable to:
Payee:
Address:
C
For WDVA Use Only.
Total amount requested for
reimbursement: $
Total amount not approved:
$
Total amount approved for reimbursement:
WDVA 0056F (09/15)
W:\Templates\WDVA_0056F_TVSO_Reimbursement_Grant_Worksheet.dot
$
You can access the most recent version of this form
from the WDVA website at www.WisVets.com/Forms.