Wis. Stats. Chapter 45	2135 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387) | WisVets.com
WISCONSIN PROPERTY TAX CREDIT PROGRAM COUNTY/TRIBE TAX ABATEMENT VERIFICATION FORM

Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].

Name of Veteran	Base File Number
Name of Applicant	Relationship to Veteran
Mailing Address
City	State	Zip Code

Veteran:

Records of the United States Department of Veterans Affairs confirm that the Veteran named above has:

☐ A schedule single or combined rating of 100% due to service connected conditions, reflecting one or more conditions that are recognized under 38 U.S.C. § 1114 or 38 U.S.C. § 1134;

☐ Check this box only if the disability rating indicated above is considered Permanent & Total; – or –

☐ A 100% disability rating based on individual unemployability;

☐ Check this box only if the disability rating indicated above is considered Permanent & Total; – or –

☐ A disability rating of 100% due to service connected conditions with a future examination(s) reflecting one or more conditions that are recognized under 38 U.S.C. § 1114 or 38 U.S.C. § 1134, or based on individual unemployability with a future examination(s) (this does not include temporary evaluations of 100% recognized under 38 C.F.R. § 4.28, 38 C.F.R. § 4.29, or 38 C.F.R. § 4.30 - prestabilization ratings, hospitalizations and convalescent ratings). Ratings with future examinations are not considered permanent and total. Eligibility terminates upon rating level that falls below 100%.

The effective date of the award is .

Un-Remarried Surviving Spouse:

Records of the United States Department of Veterans Affairs confirm that the veteran named above had:

☐ A schedule single or combined rating of 100% due to service connected conditions at the time of his/her death. This rating reflects one or more conditions that are recognized under 38 U.S.C. § 1114 or 38 U.S.C. § 1134; – or –

☐ A 100% disability rating based on individual unemployability at the time of his/her death.

The effective date of the award is .

DIC Recipient:

☐ The Widow/Widower, following the death of his/her spouse/veteran began to receive and continues to receive, Dependency and Indemnity Compensation as defined in 38 U.S.C. § 101(14) effective .

By signing this form, I certify that I have an active accreditation issued by the United States Department of Veterans Affairs (USDVA) under the authority granted in section 5902 of title 38, United States Code which grants me access to the information verified above.

Name:	County/Tribe:
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Signature:	Date: