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
CERTIFICATION REQUEST FOR VETERANS ENTREPRENEURSHIP GRANT
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.

Wisconsin Statute § 45.437 provides a Veteran Entrepreneurship Grant for nonprofit organizations that provide entrepreneurship training or other assistance to veteran entrepreneurs to improve employment outcomes.

TO BE COMPLETED BY NONPROFIT ORGANIZATION
We request the Wisconsin Department of Veterans Affairs (WDVA) verify that the program participant below is a veteran and a resident of this state in accordance with Wis. Stats. §§ 45.01(12) and 45.02.
Nonprofit Name:
Nonprofit FEIN #:
Nonprofit Street Address:
Nonprofit City, State, Zip Code:
Authorized Signature	Date
TO BE COMPLETED BY PROGRAM PARTICIPANT/VETERAN
Participant Name:
Participant Social Security No:
Participant Street Address:
Participant City, State, Zip Code:
Please check all that apply.
1. 2.	I am a veteran and resident of this state as previously determined by WDVA through records maintained by WDVA and in myWisVets. I authorize WDVA and the U.S. Department of Veterans Affairs to verify my honorable service in the U.S. Armed Forces and release this information to the nonprofit organization listed above.
3.	I have a service-connected VA disability rating of at least 50 percent, under 38 USC 1114 or 1134. I authorize WDVA and the U.S. Department of Veterans Affairs to verify my disability rating percentage and effective date, and release this information to the nonprofit organization listed above.
Under penalties of law, I declare that the above information is true, correct, and complete, to the best of my knowledge.
Veteran Signature	Date