Wis. Stats. Chapter 45	P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387) | WisVets.com
RETRAINING GRANT APPLICATION
WDVA Base File #	COUNTY NUMBER

The information requested below is authorized for collection by Ch. 45, Wis. Stat., and VA 1.02, Wis. Admin. Code and is used to determine eligibility for department programs. 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. Under the Civil Rights Act, at 42 USCS 2000e-2, this department does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in the provision of services. Under § 111.321, Wis. Stats., no employer may engage in any act of employment discrimination on the basis of age, race, creed, color, disability, marital status, sex, national origin, ancestry, arrest record, conviction record, membership in the national guard, state defense force or any reserve component of the United States or this state, or use or nonuse of lawful products off the employer’s premises during nonworking hours, subject to certain exceptions enumerated at §§ 111.33 to 111.365, Wis. Stats.
NAME OF VETERAN	NAME OF CO-APPLICANT
Last	First	M.I.	Last	First	M.I.
Years at this Rent
Street Address	City	State	Zip	address	Own
If the applicant is married and not in the process of obtaining a divorce, the applicant’s spouse must complete the co-applicant column. If the applicant is separated, provide the date of separation and the spouse’s address.
VETERAN	CO-APPLICANT
Married Unmarried Separated Date: Unmarried includes single, widowed, or divorced.	Married Unmarried Separated Date: Unmarried includes single, widowed, or divorced.
Date of Birth:	Home Telephone:	Date of Birth:	Home Telephone:
( )	( )
Social Security #:	VA Claim #:	Social Security #:	VA Claim #:
Email Address:	Email Address:
DEPENDENTS OTHER THAN SPOUSE
NAME AND RELATIONSHIP	DATE OF BIRTH	ADDRESS (IF DIFFERENT FROM VETERAN)

Veteran's Name
WDVA Base File #
LIQUID ASSETS	Checking account balances, savings account balances, and the value of securities (stocks, bonds, CDs, mutual funds, etc.) must be shown below. Do not include assets in retirement accounts (IRAs, 401K accounts, etc.). The balance column for checking and savings accounts must be filled in. If none, please write none.
TYPE OF ASSET	FINANCIAL INSTITUTION/NAME OF STOCK, ETC.	CURRENT VALUE OR BALANCE
$
$
$
$
$
$
UNUSUAL EXPENSES	Please list required medical or dental expenses or maintenance/alimony payments only incurred or to be incurred during the period of your training.
ITEM	MONTHLY COST
$
$
$
PREVIOUS EXPENSES	Prior to the retraining for which you are currently enrolled or for which you will be enrolled, indicate the highest level of education you have completed.
Less than High School	High School	Associate’s Degree
Bachelor’s Degree	Master’s Degree	Other:
WARNING: You are not eligible to receive a Retraining Grant if you receive any reimbursement under the Veterans Education (VetEd) Grant Program for courses completed during the same semester(s) for which you request a Retraining Grant.
INCOME
TYPE	WHOSE?	GROSS MONTHLY	SOURCE	WILL IT STOP? WHEN?
Vet Co-app	Date
Wages	$	Employer and Address
Wages	$	Employer and Address
Unemployment Insurance Comp.	$	Employer and Address
Sick pay	$	Employer and Address
Worker’s Compensation	$	Employer and Address
Non-VA Pension	$	Source
Regular S.S.	$	FEDERAL GOVERNMENT
Dis. S.S. (SSD)	$	FEDERAL GOVERNMENT
Supp. S.S. (SSI)	$	FEDERAL GOVERNMENT
VA Pension	$	FEDERAL GOVERNMENT
AFDC	$	FEDERAL GOVERNMENT
Food Stamps	$	FEDERAL GOVERNMENT
Rental Income	$	Property Address I pay utilities Tenant pays
Dividends/Interest	$	Type of Asset
Other	$

Veteran's Name
WDVA Base File #
EMPLOYMENT	The WDVA Retraining Grant (RTG) is restricted to those who became unemployed, underemployed, or received a notice of termination of employment within the period beginning one year (365 days) prior to the date the application is received by the Department or the county veterans service officer of the county in which the veteran is living. The Applicant must have been employed for at least six consecutive months with the same employer or in the same or similar occupations and at least one day of that employment must have been within the period beginning one year prior to the date the application is received. A person who is “underemployed” is one whose current annual income from employment does not exceed federal poverty guidelines. The loss of employment or the reduction of income must not have been caused by the voluntary actions of the veteran.
Please list all employers for whom you have worked in the past year.
Employer/City	Starting Date	Ending Date*	Monthly Gross	Reason for Leaving or Reduction of Income
1.	$
2.	$
3.	$
*or date income was reduced. If the most recent employment, or the employment at which you worked for at least six months was self-employment, you must submit a copy of the tax returns on which you reported the self-employment income.
EXPECTATIONS	Please explain briefly how this training/education will lead to gainful employment.
Check this box only if utilizing an approved OJT Program.
APPLICANT’S SIGNATURE	I certify that I have read or have had read to me all questions from this application
and that the answers are true and complete to the best of my knowledge and belief.
Signature	Date
WARNING:	If you knowingly make any false statement or submit fraudulent evidence in connection with this application, you are subject to severe penalties provided by law including fine, imprisonment, or both, and suspension of all veterans benefits from the Department.

Veteran's Name
WDVA Base File #

SCHOOL: ASSESSMENT COUNSELOR’S CERTIFICATION
Except for a veteran engaged in a structured on-the-job training program, the RTG is restricted to those veterans who are currently enrolled in a training course in a Wisconsin technical college or an approved proprietary school. The anticipated completion date of a course of instruction may not be more than 2 years from the date the department receives the application. “Course of instruction” means all of the school training which will be completed before the applicant seeks new employment.
1. Name of the school where the student is enrolled:
2. Enrollment dates for this school period:
3. Number of credits this school period:
4. Number of credits next school period (if any):
5. What is the student’s educational objective (name of program or degree)?
6. When could the student complete this educational objective? Date:
Month Day Year
To qualify for an RTG, the student must seek the advice of an assessment counselor (or vocational guidance counselor) regarding the course of instruction undertaken. The Assessment Counselor must sign the certification below.
I certify that I have discussed the course of instruction this veteran is pursuing and that the training the veteran is receiving may reasonably be expected to lead to gainful employment and is appropriate given the veteran’s prior training and job experience.
COMMENTS:
Signature of Assessment Counselor	Title and School/Employer	Date
Email Address:	Telephone:	( )
SCHOOL: FINANCIAL AIDS OFFICIAL’S CERTIFICATION
1.	What is the cost of tuition, fees, and books?	Dates of Enrollment (start and end dates)
$
$
$
2.	Students must apply for all financial assistance available during the school period and all available financial aid must be reported. The department may not provide a grant if other financial assistance is available to meet the veteran's needs. Has the student received or will the student receive any financial assistance during the period of training? Examples of such assistance are: Vocational Rehabilitation, employer tuition assistance, VA educational benefits, scholarships, and student grants. If so, please indicate below. (Do not include loans.)
TYPE OF ASSISTANCE	AMOUNT	PERIOD COVERED BY THE ASSISTANCE
$
$
$
$
MGIB Chapter 30 or 31 Benefits	$ /month
I certify that this applicant is enrolled at the school shown above. I further certify that the information regarding date of enrollment, credits, educational objective, and financial assistance is correct to the best of my knowledge.
COMMENTS:
Signature of Financial Aids Official	Title and School/Employer	Date
(Must be Authorized for WDVA Programs)
Email Address:	Telephone:	( )
Veteran's Name
WDVA Base File #
WORKFORCE DEVELOPMENT: VERIFICATION OF AVAILABLE AID
Students must apply for all financial assistance available during the school period, and all available financial aid must be reported including aid identified below in 2(a) and 2(b).
1.	Total length of training program:	From:	To:
2.	Total anticipated financial aid (in addition to the RTG) that the veteran will receive during the above training period. Please identify date(s) the aid will be received.
a. Workforce Innovation and Opportunity Act (WIOA):	$	Date:
b. Trade Adjustment Act (TAA) Aid:	$	Date:
c. Other aid available through DWD:	$	Date:
COMMENTS:
Signature of WIA Official	Title	Date
Email Address:	Telephone:	( )
Signature of TAA Official	Title	Date
Email Address:	Telephone:	( )
(Contact a WIA service provider, TAA service provider, or Veterans Employment Representative at your local Wisconsin Job Center. Visit www.dwd.state.wi.us/dws/directory/ or call 18882589966 for the phone number and address of your nearest Wisconsin Job Center.)