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
DECLARATION OF AID
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].

This form is designed to provide information about county–administered benefits to WDVA for the Veterans Assistance Grant Program. It is to be completed and signed by the County Veterans Service Officer or other person as designated by the County Board or Executive.
Applicant’s Name:	County:
I certify that this applicant has applied for all federal, state, or county aid administered by the county. Aid is available as listed below: Note: If aid is unavailable, enter a zero. Do not leave the line blank.
Subsistence or Health Care Aid
Veterans Service Commission Funds	$
If zero, provide reason: Funds exhausted Other (please explain):
Health Care Aid Only
Medicaid (Medical Assistance)	$	deductible
Badger Care	$	deductible
Other (please list):	$
$
Subsistence Aid Only
Food Share Benefits (formerly called Food Stamps)	$
Emergency Assistance	$
Medicare Premium Assistance (QMB, SLMB)	$
Unemployment Insurance (also called Unemployment Compensation or UC)	$
Worker’s Compensation	$
W2 (AFDC)	$
Other (please list):	$
$
County Agent’s Name:	Title:
Signature:	Date: