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
ASSISTANCE TO NEEDY VETERANS GRANT APPLICATION
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].	Base File #
The provision of your social security number is voluntary. Failure to provide your social security number may result in an information processing delay.	County
County Contact
Veteran's Name	Mr. Ms.
First Name	Middle Name	Last Name	Suffix
Address	City	State	Zip Code
Birth Date	Social Security Number
Applicant's Name	Mr. Ms.
Veteran	Relationship to Veteran Unremarried Spouse/Dependent of veteran killed in action or line of duty
Spouse/Dependent of activated or deployed veteran
First Name	Middle Name	Last Name	Suffix
Applicant's Birth Date	Applicant's Social Security Number
Patient's Name	Mr. Ms.
Veteran	Relationship to Veteran Spouse/Widow(er) Dependent
First Name	Middle Name	Last Name	Suffix
Patient's Birth Date	Patient's Social Security Number
Applicant's Marital Status	Unmarried (includes widowed and divorced) Married Separated
Select Desired Benefit	(Lifetime maximum of $7,500 for all ANV Grant types combined)
Subsistence Aid	($3,000 maximum per 12 month period) *MUST APPLY WITHIN 120 DAYS OF INCOME LOSS
Health Care Aid Components	Vision Care:	Qualifying Care including vision exam and one set of eyeglasses up to $400 per consecutive 12 month period
Dental Care:	Qualifying Care up to $500 per consecutive 12 month period
Upper Denture up to $1,875 per consecutive 48 month period
Lower Denture up to $1,875 per consecutive 48 month period
Hearing Care:	Qualifying Care up to $200 per consecutive 12 month period
Left Hearing Aid up to $1,875 per consecutive 48 month period
Right Hearing Aid up to $1,875 per consecutive 48 month period
A Description of Benefits (DOB) authorizing care for a 90-day period will be posted for approved applications. It is to be printed by the CVSO for delivery to the provider who will complete the "Request for Payment" section and submit to WDVA for payment. Care must be completed before the "Expiration" date on the DOB. If an outstanding DOB exists, binding quotes from a provider are necessary in order to have an additional DOB issued.
Living Arrangements	Own Home	Mobile Home	Live With Roommates	VA Facility
Rent	Homeless	Live With Relatives	VAP Facility
VA Health Care System (Wisconsin law requires use of all available resources and agencies [VA2.01(2)(a)])
Date veteran applied to Federal VA health care system
Has veteran been enrolled into the system? No Yes Date enrolled
Does the veteran have a service–connected disability? No Yes Disability rating	%
List Disabilities
Health Insurance
I do not have health insurance that covers dental, vision or hearing care
I have health insurance that covers all or a portion of Dental Vision Hearing
Spouse and Legal Dependents Living With Applicant
First Name	Last Name	Birth Date	Relationship to Veteran
Spouse Dependent
Spouse Dependent
Spouse Dependent
Spouse Dependent

Name
Base File #
Income —Verification Required (Veteran, Spouse, or Any Dependent Name)
Recipient 1
Current Income	$	Frequency Monthly Annually Semi–Annually Quarterly
Semi–Monthly Bi–Weekly Weekly
Income Type	National Guard/Reserve	Dividends
Compensation – VA	Interest
Compensation – Unemployment (insurance)	Wages
Compensation – Workers	Employer
Sick/Disability Pay (from employer or insurance)	Overtime
Pension – Other than Federal VA	Bonuses
Pension – Federal VA	Commissions
Social Security – Regular	Child Support
Social Security – Disability (SSD)	Retirement (pay)
Supplemental Security Income (SSI)	Student Financial Aid (all types)
Aid to Families with Dependent Children	Federal GI Bill
Food Share (formerly called Food Stamps)	State or Federal Voc Rehab
Rental(income)	Other
Recipient 2
Current Income	$	Frequency Monthly Annually Semi–Annually Quarterly
Semi–Monthly Bi–Weekly Weekly
Income Type	National Guard/Reserve	Dividends
Compensation – VA	Interest
Compensation – Unemployment (insurance)	Wages
Compensation – Workers	Employer
Sick/Disability Pay (from employer or insurance)	Overtime
Pension – Other than Federal VA	Bonuses
Pension – Federal VA	Commissions
Social Security – Regular	Child Support
Social Security – Disability (SSD)	Retirement (pay)
Supplemental Security Income (SSI)	Student Financial Aid (all types)
Aid to Families with Dependent Children	Federal GI Bill
Food Share (formerly called Food Stamps)	State or Federal Voc Rehab
Rental(income)	Other
Required – For Subsistence Aid Only Income lost due to illness, injury, or natural disaster
Date of Stop/Decrease
Income Before Stop/Decrease	Frequency Monthly Annually Semi–Annually Quarterly
$	Semi–Monthly Bi–Weekly Weekly
The reason for loss of income was due to
Illness Injury (send a copy of police/fire report if applicable) Natural Disaster
NOTE: If aid is available for this type of incident and the applicant hasn't applied for it, a written explanation will be required.
Liability insurance available	Yes No	Disability insurance available	Yes No
Lawsuit will be filed or is pending	Yes No	Workers Compensation available	Yes No
Crime Victim Compensation available	Yes No
Explanation of Incident
NOTE: If this was work related, the applicant should apply for Workers Compensation. If it occurred on private property, the applicant should check into liability insurance coverage. The applicant may be asked to provide additional information.
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Name
Base File #
Nature of Incident
Date of Incident	Time of Day/Night
Location of Incident	Phone
Address	City	State	Zip Code
Witnesses
Name 1	Phone
Address	City	State	Zip Code
Name 2	Phone
Address	City	State	Zip Code
Give your actions and whereabouts for at least four (4) hours prior to the incident. Include the quantity and type of alcoholic beverages and/or drugs ingested, if any. If none, so state. Give a detailed account of the incident itself.
Liquid Assets (In Veteran, Spouse, or Any Dependent Name)
Owner 1	I have no assets
Asset Type	Value	Asset Type	Value
Checking Account	$	Government Pension/Retirement Plan	$
Savings Account	$	Cash Value of Life Insurance	$
Money Market	$	Stocks (or stock accounts)	$
Certificate of Deposit	$	Bonds (or bond accounts)	$
401K Plan	$	Custodial Accounts (Children or Grandchildren)	$
403B Plan	$	Gambling Winnings	$
IRA (Roth and Regular)	$	Tax Refunds	$
Company Pension/Retirement Plan	$	Other	$
Owner 2	I have no assets
Asset Type	Value	Asset Type	Value
Checking Account	$	Government Pension/Retirement Plan	$
Savings Account	$	Cash Value of Life Insurance	$
Money Market	$	Stocks (or stock accounts)	$
Certificate of Deposit	$	Bonds (or bond accounts)	$
401K Plan	$	Custodial Accounts (Children or Grandchildren)	$
403B Plan	$	Gambling Winnings	$
IRA (Roth and Regular)	$	Tax Refunds	$
Company Pension/Retirement Plan	$	Other	$
I certify that I have read, or have had read to me, all questions from this application and this paragraph and that my answers are true and complete to the best of my knowledge, and that I will promptly notify WDVA of any changes. I have applied for and accepted all benefits available from other agencies or organizations. If I receive, or am eligible to receive, money from another source which duplicates aid I received from this program, I will repay WDVA as soon as possible. I understand that I must provide the Wisconsin Department of Veterans Affairs, either personally or through my County Veterans Service Officer, with any information requested by the department within 30 days of the date of the request or I may be denied any benefit. I authorize the department and any of its employees to request and review any county, state or federal records relating to this application. I consent to the release by the Federal Department of Veterans Affairs (VA), Social Security Administration, Wisconsin Department of Revenue (DOR), and the County Veterans Service Office (CVSO) of all information necessary to process this grant application.
Phone	( )	Signature	Date
WARNING: If you knowingly make any false statement or submit fraudulent evidence in connection with this application, you are subject to severe penalties provided by law including fine, imprisonment or both and suspension of all veterans benefits from WDVA.