Wis. Stats. Chapter 45	2135 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387)
REQUEST FOR CERTIFICATION FOR WISCONSIN VETERAN STUDENT ASSISTANCE GRANT
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].

THIS FORM IS FOR SUBMISSION TO THE WISCONSIN DEPARTMENT OF VETERANS AFFAIRS (WDVA) Instructions: 1) Complete the Request For Certification For Wisconsin Veteran Student Assistance Grant (WDVA 2059). 2) Attach a copy of the veteran’s DD Form 214, Certificate of Release or Discharge from Active Duty, and any other supporting documentation, if applicable. 3) This application and the appropriate supporting documentation can be mailed to: Wisconsin Dept. of Veterans Affairs, Attn: Veterans Assistance Section, P.O. Box 7843, Madison, WI 53707-7843; emailed to WisVets@dva.wisconsin.gov; or faxed to (608) 267-0403. NOTE: WDVA’s role is to certify the veteran’s eligibility. It is the school’s role to approve the student (i.e. veteran, eligible child, or eligible spouse) for the grant.
Veteran’s Name (Print)	Veteran’s Date of Birth	Veteran’s Social Security No.
Veteran’s Address *	Veteran’s Email Address *
( )
City, State, Zip Code	Veteran’s Telephone No. *
*If the veteran is deceased and the student is at least 18 years of age, these fields shall contain the student’s information. If the student is not yet 18 years of age, the information in the aforementioned fields shall belong to the student’s guardian. The veteran’s death certificate or casualty report must be submitted with this application. I am requesting certification based on my status as (check as many as apply):
Veteran (Myself)
Spouse of Veteran
Un-remarried Surviving	Student’s Full Name	Student’s Date of Birth
Spouse of Veteran
Child of Veteran	Student’s Social Security No. (required for Wisconsin Higher Educational Aids Board credit tracking)
Student’s Campus ID No.
I will attend:
Full Name of Campus ( DO NOT ABBREVIATE)	Start Date (mo/yr)
My signature below affirms that I understand and agree to all of the following: I must also apply the Wisconsin Veteran Student Assistance Grant for the tuition charged to me by a private nonprofit institution that is a member of the Wisconsin Association of Independent Colleges and Universities that I am or will be enrolled in and that failure to be enrolled in one of these private nonprofit institutions will prevent me from receiving any benefits to which I might otherwise have been entitled; and The Wisconsin Association of Independent Colleges and Universities require my social security number for verification by the Wisconsin Higher Educational Aids Board (HEAB) for program eligibility, for federal and state reporting requirements, and for program evaluation purposes; and The information contained in this form and any related information may be shared for the purposes of processing my application and implementing this program, with and among the Wisconsin Association of Independent Colleges and Universities, the WDVA, and the HEAB. Under penalty of law, I further attest that all of the information provided on this form and related documents is true and complete to the best of my knowledge. I agree to inform the school(s) named above and WDVA of any change in the circumstances upon which this application is based.
Applicant’s Signature (The veteran must sign if alive and legally competent.)	Date
Student’s Signature (if different from Applicant)	Date