Wis. Stats. Chapter 45	2135 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (1-800-947-8387)
VERIFICATION OF ILLNESS OR DISABILITY Assistance to Needy Veterans Grant — Subsistence Aid	County Number

A.	TO BE COMPLETED BY THE PATIENT Please release the information requested to the Wisconsin Department of Veterans Affairs.
1. Veteran’s Name:	2. Patient’s Name: (if different)	3. WDVA # or Veteran’s Birth Date:
4. Patient’s Address:	5. Date I feel I became ill/disabled:
6. Patient's Signature: Date:
B.	TO BE COMPLETED BY A LICENSED ADNVANCED PRACTICE NURSE PRESCRIBER, PHYSICIAN OR OPTOMETRIST
Refer to the date listed in number 5 above by the patient. Please answer all questions fully. Unanswered questions will delay emergency aid.
1. Diagnosis of illness/disability:
2. Date illness or injury caused a loss or reduction of employment:
3. I estimate the veteran was or will be incapacitated for the following number of days following the date noted in #2 directly above:
not incapacitated 30 60 90 days or longer	incapacitation is permanent
HEALTH CARE PROVIDER’S COMMENTS:
HEALTH CARE PROVIDER INFORMATION: WARNING: ONLY A LICENSED ADVANCED PRACTICE NURSE PRESCRIBER, PHYSICIAN OR OPTOMETRIST MAY SIGN THIS FORM. THE FORM WILL NOT BE ACCEPTED IF IT IS SIGNED BY ANYONE ELSE. (print or type) ( ) Name Title Telephone Address Email WI Credential Number Health Care Practitioner’s Signature (NO STAMPED SIGNATURES) Date Signed