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 Bus Pass Reimbursement Request Form

Tribe	Number Purchased
Tribal Employee	Unit Price
Total Cost	$
Quantity Distributed
Ending Inventory
For Period
Date	Name of Veteran	Address	Phone #	Quantity	Bus Pass #
Total

I certify that the information provided in the Bus Pass 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 BUS PASS REIMBURSEMENT REQUEST

Use the form to itemize bus pass purchase for Veterans.

● Attach legible photocopies of proof of expenses and payments for the bus pass purchase.

● Use additional form(s) as necessary.

To request reimbursement for documented veterans bus pass 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:

Date – Date issued bus pass (mm/dd/yy).

Name – Veteran’s name receiving the bus pass.

Address – Include Veteran’s complete mailing address.

Phone – Include Veteran’s phone number and/or cell phone number.

Quantity – Include the number of passes issued to the Veteran.

Bus Pass Number – Include the number on the bus pass that is issued to the Veteran.

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