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
APPLICATION FOR VETERANS EMPLOYMENT GRANT PROGRAM
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].
The provision of employee social security number is voluntary. Failure to provide the social security number may result in an information processing delay.
Wisconsin Statute § 45.437, provides a Veteran Employment Grant for employers, except local, state, and federal government agencies, who hire veterans that have a service-connected Federal VA disability rating of at least 50% (disabled veteran) on the hire date. For each disabled veteran the employer employs for 12 consecutive months to work a full-time (2080 hours per year, including paid leave and holidays) job at the employer’s business in this state, $2,500 following the first 6 months of employment, and $2,500 following the second 6 month period in which the veteran is employed. For each disabled veteran the employer employs for 12 consecutive months to work a part-time (fewer than 2080 per year, including paid leave and holidays) job at the employer’s business in this state, up to $1,250 following the first 6 months of employment, and up to $1,250 following the second 6 month period in which the veteran is employed. To apply for a grant, complete the following and email to vetsbenefitsgrants@dva.wisconsin.gov or mail to Wisconsin Department of Veterans Affairs, Grants Unit, 2135 Rimrock Road, P.O. Box 7843, Madison, WI 537077843. EMPLOYER INFORMATION Employer: FEIN #: Contact Name: Email Address: Phone #: Street Address: City, State, Zip: EMPLOYEE (VETERAN) INFORMATION Employee Name: Social Security #: Email Address: Phone #: Street Address: City, State, Zip: VERIFICATION OF PRESENT EMPLOYMENT Employee Date of Hire: Present Position: Full-Time ☐ Part-Time ☐ Current Base Pay: Annual ☐ Monthly ☐ Weekly ☐ Hourly ☐ Dates of 1st 6 months of employment: to (mm/dd/yyyy) Number of Hours Worked Date of 2nd 6 months of employment: to (mm/dd/yyyy) Number of Hours Worked Note: The following documents are required when submitting your application: WDVA Form 2642 – Certification Request for Veterans Employment Grant. Payroll register and/or payroll journal to verify employment, hours worked and period of employment. Form W-9 Request for Taxpayer Identification No. and Certification: https://vendornet.wi.gov/Forms.aspx
Under penalties of law, I declare that the information on this form and all attachments are true, correct, and complete to the best of my knowledge and belief.
Signature	Date