Wis. Stats. Chapter 45	2135 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387)
CERTIFICATION REQUEST FOR VETERANS EMPLOYMENT GRANT
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.

Wisconsin Statute § 45.437, provides a Veteran Employment Grant for employers who hire veterans whom have a service-connected Federal VA disability rating of at least 50% on the hire date.

TO BE COMPLETED BY EMPLOYER
We request the Wisconsin Department of Veterans Affairs (WDVA) verify that the Employee below is a veteran and a resident of this state in accordance with sections 45.01(12) and 45.02, Wis. Stats., and has a service-connected Federal VA disability rating of at least 50%, under 38 USC 1114 or 1134.
Employer Name:	Phone #:
Employer FEIN #:
Employer Street Address:	Email:
Employer City, State, Zip Code:
Employer Contact Name:
Employer Authorized Signature	Date
TO BE COMPLETED BY EMPLOYEE
Employee Name:	Phone #:
Employee Social Security Number:
Employee Street Address:	Email:
Employee City, State, Zip Code:
Please check all that apply.
1.	I authorize WDVA to verify my honorable service in the U.S. Armed Forces, and release this information to my employer listed above.
2.	I have a service-connected VA disability rating of at least 50 %, under 38 USC 1114 or 1134. I authorize WDVA to verify my disability rating percentage and effective date, and release this information to my employer listed above.
3.	I have attached a copy of my disability documentation from the United Stated Department of Veterans Affairs that states I have a service connected VA disability rating of at least 50 %, under 38 USC 1114 or 1134.
4.	I have attached a copy of my DD Form 214 (Certificate of Release or Discharge from Active Duty).
Under penalties of law, I declare that the above information is true, correct and complete, to the best of my knowledge.
Veteran Signature	Date