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

INSTRUCTIONS

VETERANS ASSISTANCE GRANT APPLICATION (SUBSISTENCE AID)

Please submit this application if you are applying for Subsistence Aid due to an illness, injury or natural disaster which has resulted in a loss of income.

*THIS APPLICATION MUST BE SUBMITTED WITHIN TWELVE (12) MONTHS FOLLOWING THE DATE OF THE LOSS OF INCOME*

Subsistence Aid will be limited to the difference between the amount of earned and unearned income available before the loss of income and the earned and unearned income being received after the loss of income, subject to limitations under § 45.40(1m)(b) and (3), Stats.

If you are the veteran completing this application, please complete the “Veteran’s Name” section.

If you are the spouse or dependent of the veteran completing this application:

For yourself; please complete the “Veteran’s Name” and “Applicant’s Name” sections.

On behalf of the veteran, please complete the “Applicant’s Name” and “Patient’s Name” sections.

There is a $3,000 maximum per 12-month period for this benefit and a combined lifetime maximum of $7,500 for Health Care Aid and Subsistence Aid.

To be eligible, an applicant must meet the following requirements:

Be a veteran as defined in Wis. Stat. § 45.01(12).

Household income at or below 200 percent of the federal poverty guidelines in effect at the time the application is received by the department. Current federal poverty guidelines can be found here: https://aspe.hhs.gov/poverty-guidelines.

Spouse or dependent of an activated or deployed member of the U.S. Armed Forces or Wisconsin National Guard must submit evidence that the service member has been deployed or activated, that due to the activation or deployment, a loss of income has occurred, that an economic emergency has occurred during the activation or deployment, and that the spouse and dependents are residents of this state.

Does not have more than six (6) months in available liquid assets and available income to meet basic subsistence needs and is not eligible to or did not receive aid from other sources to meet those needs. The amount of liquid assets does not include the first $50,000 of cash surrender value of any life insurance policy.

Required Documentation:

Complete Application for Veterans Assistance Grant – Subsistence Aid (Form WDVA 2453).

Declaration of Aid (Form WDVA 2451) signed by County Agent, CVSO, or the economic assistance consortium. Must be submitted with the application.

Verification of Illness or Disability (Form WDVA 2045) must be received from the treating licensed health care provider, if loss of income is due to illness or injury.

Notice of Decision (NOD) letter from local consortium that indicates the applicant has applied for Food Share and Medicaid or Badger Care.

Copy of bank statements for the six (6) months immediately preceding date of application (highlight/circle living expenses).

* If bank statements cannot be obtained please submit the following: copy of current lease or mortgage statement for applicant’s primary residence, proof of current medical insurance premiums, and copies of electric, heat, and water bills for applicant’s primary residence, and applicant’s phone bill for the past six (6) months.

Any other documentation or verification requested by the Department.

*NOTICE: Application will be terminated if requested documentation and/or verification is not received at the department’s central office within 60 days of notification for additional documentation and/or verification.

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

VETERANS ASSISTANCE GRANT APPLICATION (SUBSISTENCE AID)

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.	Base File #
County
County Contact
Veteran’s Name (To be completed by veteran or if the veteran’s spouse/dependent is applying for benefits) Mr. Ms. First Name Middle Name Last Name Suffix Address City State Zip Code Date of Birth Email Address Social Security Number

Applicant’s Name (To be completed only if veteran is not completing the application) Mr. Ms. 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 Address Middle Name Last Name Suffix Applicant’s Date of Birth Applicant’s Email Address Applicant’s Social Security Number

Patient’s Name (Veteran’s information if veteran is not completing the application) Mr. Ms. Relationship to Veteran Spouse/Widow(er) Dependent First Name Middle Name Last Name Suffix Address Middle Name Last Name Suffix Patient/Veteran’s Date of Birth Patient/Veteran’s Email Address Patient/Veteran’s Social Security Number
Veteran’s Name:
Base File #:
Applicant’s Marital Status Unremarried (includes widowed and divorced) Married Separated

Income lost due to illness, injury or natural disaster ($3,000 maximum per 12-month period.) *MUST APPLY WITHIN TWELVE (12) MONTHS OF VERIFIED LOSS OF INCOME Date of Stop/Decrease (Income) Income before Stop/Decrease Frequency Monthly Annually Semi-Annually Quarterly Semi-Monthly Bi-Weekly Weekly Reason for Loss of Income Illness Injury Natural Disaster (send a copy of police/fire report, if applicable) *NOTE: If aid is available for this type of incident and the applicant has not applied for it, a written explanation as to why 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 is a result of a work-related incident, the applicant needs to apply for Workers Compensation. If it occurred on private property, the applicant needs to check into liability insurance coverage. The applicant may be asked to provide additional information. Nature of illness, injury or natural disaster Date of Incident Time of day/night Location of Incident Phone Number Address City State Zip Code Witnesses Name 1 Phone Number Address City State Zip Code Name 2 Phone Number Address City State Zip Code

Veteran’s Name:
Base File #:

Explanation of Incident, cont. Please provide an explanation of 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. Attach additional sheets if necessary.

Under penalty of applicable law, I certify that the explanation of the incident, above, is true and complete to the best of my knowledge and belief. Applicant’s Signature Date

Veteran’s Name:
Base File #:

Living Arrangements Own Home Mobile Home Live with Roommates VA Facility Rent Homeless Live with Relatives VAP Facility Spouse and Legal Dependents Living with Applicant First Name Last Name Birth Date Relationship to Veteran Spouse Dependent Spouse Dependent Spouse Dependent Spouse Dependent

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 Hearing Vision VA Health Care System (Wisconsin law requires use of all available resources and agencies [Wis. Admin. Code § VA 2.01(2)(a)] Date veteran applied to Federal VA health care system Has veteran been enrolled into the system? No Yes If yes, Date enrolled Does the veteran have a service-connected disability? No Yes If yes, Disability rating %

Income – Verification Required (Veteran, Spouse or any Dependent) For Past 30 Days Recipient 1 Current Income $ Frequency Monthly Annually Semi-Annually Quarterly Semi-Monthly Bi-Weekly Weekly Income Type Wages – Employer $ Aid to Families with Dependent Children Overtime Food Share (formerly called Food Stamps) Bonuses Rental (Income) Commissions National Guard/Reserve Sick/Disability Pay (from employer or insurance) Compensation - VA Child Support Compensation – Unemployment Insurance Dividends Compensation - Workers Interest Pension – Other than Federal VA Retirement (pay) Pension – Federal VA Social Security - Regular Student Financial Aid (all types) Social Security - Disability Federal GI Bill Supplemental Security Income (SSI) State or Federal Voc Rehab Other

Veteran’s Name:
Base File #:

Income – Verification Required (continued) Recipient 2 Current Income $ Frequency Monthly Annually Semi-Annually Quarterly Semi-Monthly Bi-Weekly Weekly Income Type Wages – Employer $ Aid to Families with Dependent Children Overtime Food Share (formerly called Food Stamps) Bonuses Rental (Income) Commissions National Guard/Reserve Sick/Disability Pay (from employer or insurance) Compensation - VA Child Support Compensation – Unemployment Insurance Dividends Compensation - Workers Interest Pension – Other than Federal VA Retirement (pay) Pension – Federal VA Social Security - Regular Student Financial Aid (all types) Social Security - Disability Federal GI Bill Supplemental Security Income (SSI) State or Federal Voc Rehab Other

Liquid Assets (In Veteran, Spouse, or any Dependent’s Name) Owner 1 I have no assets Asset Type Value Asset Type Value Checking Account $ Custodial Accounts (Children or Grandchildren) $ Savings Account $ Gambling Winnings $ Money Market $ Tax Refunds $ Certificate of Deposit $ Other $ Cash on Hand $ Owner 2 I have no assets Asset Type Value Asset Type Value Checking Account $ Custodial Accounts (Children or Grandchildren) $ Savings Account $ Gambling Winnings $ Money Market $ Tax Refunds $ Certificate of Deposit $ Other $ Cash on Hand $
Veteran’s Name:
Base File #:
Living Expenses (Applicant’s Primary Residence) Living Expense Six Month Avg Living Expense Six Month Avg Rent/Mortgage $ Child Care Required $ Food $ Electricity/Heat $ Current Medical Insurance Premium $ Water $ Current Prescribed Medication $ Telephone $ Essential Travel $

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 60 days of the date of the request or I may be denied this 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.