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 DISABLED VETERANS AND UNREMARRIED SURVIVING SPOUSES PROPERTY TAX CREDIT
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].
The provision of your social security number is voluntary. Failure to provide your social security number may result in an information processing delay.

Instructions: All those requesting certification for veterans property tax credit must complete this form in full and attach required documentation as follows: 1) DD Form 214, Certificate of Release or Discharge from Active Duty; 2) certified death certificate (if the veteran is deceased); 3) certified marriage certificate (if the veteran is deceased); 4) Federal VA basic service-connected disability rating notification letter. 5) Original copy of Form WDVA 1805 VETERANS’S RESIDENCY AFFIDAVIT if needed to establish Wisconsin was your “Home of Record” or to establish a 5 year continuous residency. Mail this application and the appropriate supporting documents to: Wisconsin Dept. of Veterans Affairs, Attn: Wisconsin Veterans Property Tax Credit, 2135 Rimrock Road, P.O. Box 7843, Madison, WI 537077843.

Requester Name (Print)	Date of Birth
Address	Social Security Number
City, State, Zip Code	Telephone Number
Email Address
I am requesting certification for Veterans Property Tax Credit based on my status as:
Veteran (myself)	OR	Unremarried Surviving Spouse of 100% SCD veteran
Unremarried Surviving Spouse continuing to receive Federal VA Dependency and Indemnity Compensation (DIC) as defined in 38 USC 101 (14).
I am the unremarried surviving spouse of:
Full Name of Veteran	Veteran's Social Security Number
Veteran’s Date of Birth	Veteran’s Date of Death
Under penalty of law, I attest by my signature that all of the information I have provided on this and related documents is true and complete to the best of my knowledge. I agree to inform WDVA of any change in the circumstances upon which this application is based, including a change in disability rating or individual unemployability.
Signature	Date