Wis. Stats. Chapter 45	2135 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387)
TRIBAL VETERANS SERVICE GRANT PROGRAM Veterans Transportation Mileage Log and Reimbursement Request Form

Tribe	For Period
Name of Driver	State Rate Per Mile	$0.51
Address	Total Mileage
Authorized By	Total Mileage Cost
Title	Revenue Collected
Approval Date	Total Reimbursement
Travel Date	Vehicle Description	License Plate	Starting Location	Destination/Purpose	Total Miles	Mileage Cost	Revenues Collected	Name-Address-Phone
Totals	$	$

I certify that the information provided in the Veterans Transportation Mileage Log and Reimbursement Request Form for this grant is accurate. Grant funds shall be maintained in a separate account subject to audit by the Wisconsin Department of Veterans Affairs. I further agree to fully cooperate in any review and audit of grant expenditures by the department, including the provision of any relevant single audit document that establishes that grant funds previously received have been audited. I understand that pursuant to s. 45.47 Stats., if a county fails to comply with the above requirements, the Wisconsin Department of Veterans Affairs may, in addition to any other legal remedy available, reduce, suspend, or terminate the grant provided to the applicant.

The person signing below this line must be a Tribal Council Official.

Name:	Position:
Please print legibly
Phone Number	(	)	Email:
Signature:	Date:
Reimbursement check should be made payable to:
Payee:
Federal Identification Number:
Address:
For WDVA Use Only
Total amount requested for reimbursement:	$
Total amount not approved:	$
Total amount approved for reimbursement:	$

INSTRUCTIONS FOR COMPLETING TRIBAL VETERANS TRANSPORTATION MILEAGE AND REIMBURSEMENT REQUEST

Use the form to itemize all proposed eligible veterans transportation expenses.

● Attach legible photocopies of proof of expenses and payments for each item listed (if applicable).

● Use additional form(s) as necessary.

To request reimbursement for documented veterans transportation expenses, a Tribe must complete this form and submit to WDVA as follows:

1st Reimbursement Grant Period: This form must be provided to WDVA by January 15, 2016 for documented expenses incurred July 1, 2015 –	December 31, 2015.

2nd Reimbursement Grant Period: This form must be provided to WDVA by June 15, 2016 for documented expenses incurred January 1, 2016 – June 15,	2016.

A Tribe can complete and submit this form to WDVA as many times as a Tribe deems necessary throughout the fiscal year. However, the WDVA will	only reimburse a Tribe for documented and allowable expenses, twice yearly in accordance with Wis. Stats. 45.82(2) and following each of the two	reimbursement grant periods referenced above.

● Submit form(s) to: WDVA, Division of Veterans Benefits, Grants Unit, 2135 Rimrock Road, Madison, WI 53713 or email to VetsBenefitsGrants@	dva.wisconsin.gov.

Date Field and Column Definitions:

Travel Date – Date mileage incurred (mm/dd/yy).

Vehicle Description – Personal, Tribal or Contracted.

License Plate Number – License plate number of the vehicle used to transport the Veteran.

Starting Location – Indicate starting location; include complete address and city.

Destination/Purpose – Enter ending location/destination and the purpose for travel.

Total Miles – The actual miles of the trip.

Mileage Cost – Cost of actual miles traveled. This is included as a calculation on the spreadsheet.

Revenues Collected – Include any money received from riders, donations, etc.

Name/Address/Phone Number – Include the rider information.

Approval rate of reimbursing mileage for county-owned and privately-owned vehicles is in accordance with the State of Wisconsin DOA Travel Policy. The reimbursed rate shall be at the rate of .51 cents per mile.

This reimbursement is specific to mileage only. No other expenses will be considered.