Wis. Stats. Chapter 45	P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387) | WisVets.com
COUNTY TRANSPORTATION GRANT APPLICATION – SUPPLEMENT

2021-2022	County/Tribe/Band Veterans Transportation Services Report
I. Number of veterans transported and miles driven to medical appointments arranged or conducted by the U.S. Department of Veterans Affairs (USDVA).
# Rides x # Miles – 2021	JUL	AUG	SEP	OCT	NOV	DEC	2021 TOTAL
# Rides x # Miles - 2022	JAN	FEB	MAR	APR	MAY	JUN	2022 TOTAL
II. Revenue and expenses related to veteran’s transportation services to medical appointments arranged or conducted by the USDVA.
2021	2022
Transportation Service Expenses	Jul-Dec	Jan-Jun	Total
$	$	$
$	$	$
$	$	$
$	$	$
$	$	$
Totals	$	$	$
Transportation Service Revenues
Ride Fees	$	$	$
Other	$	$	$
Totals	$	$	$