Wis. Stats. Chapter 45	STATE OF WISCONSIN, DEPARTMENT OF VETERANS AFFAIRS 2135 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387)
TRIBAL VETERANS SERVICE REIMBURSEMENT GRANT WORKSHEET

Reimbursement Grant Period:	7/1/15 – 12/31/15

Reimbursement Grant Period	1/1/16 – 5/31/16

Tribal Nation:

Notice: Information requested on this form is required by the Department when applying for a reimbursement of eligible expenses.

The Department will not consider your payment request unless you complete and submit this form.

Instructions: Itemize all expenses and attach legible photocopies of proof of expenses and payments for each item listed. See reverse for instructions.

Use additional worksheets as necessary, numbering each.

Date Expense Incurred	Invoice/Statement #	Proof of Payment Type and #	Payee	Eligible Expense Description	Eligible Cost of Expense	Amount Requested for Reimbursement
Total	$	$

INSTRUCTIONS FOR COMPLETING TRIBAL VETERANS SERVICE REIMBURSEMENT GRANT WORKSHEET

Use the worksheet to itemize all proposed eligible expenses.

• Attach legible photocopies of proof of expenses and payments for each item listed.

• Use additional worksheets as necessary.

• Submit Worksheet(s) and attachments to: WDVA, Division of Veterans Benefits, Grants Unit, 2135 Rimrock Road, Madison, WI 53713 or email to VetsBenefitsGrants@dva.wisconsin.gov.

Date Field and Column Definitions

Date Expense Incurred: Date of invoice, purchase, or service rendered.

• Costs incurred prior to the beginning date or after the ending date of the grant reimbursement period are not eligible for reimbursement.

Invoice/statement #: Number on vendor invoice or bill associated with the purchase or service.

• Combined Costs: If an invoice combines costs for multiple grants or expenses, identify and explain specific costs associated with each grant expense. Attach a copy of this invoice, as well as proof of payment identified below. Use as many lines as necessary.

Proof of Payment type and #: Copy of a receipt, number on check or money order used to pay the expense. If no proof of payment number, leave blank. Attachments required:

• Expenditure Proof of Payment Examples: Copy of receipt; canceled check, with front side of check containing the amount of the check digitally printed by the bank under the signature line; Non-canceled check with bank statement showing check cleared account; payroll vouchers; Credit card statements. For acquisition expenditures, acquisition closing statements.

• Combined Proofs of Payment: If a proof of payment covers multiple expenses or grants, identify payments related to the particular grant expense on a copy.

Payee: Name of consultant, contractor, vendor, supplier, etc. to whom payment was made.

Eligible Expense Description: Describe expense briefly. Include only eligible expenses as specified in Wis. Stats. s. 45.82(5):

Information technology.

Transportation for veterans and service to veterans with barriers.

Special outreach to veterans.

Training and services provided by the department and the federal department of veterans affairs.

Salary and fringe benefit expenses incurred in 2015; salary and fringe benefit expenses incurred in

2016, except that total reimbursement for such expenses shall not exceed 50 percent of the applicable maximum grant.

Eligible Cost of Expense: The cost of the expense paid by the Tribe or Band. Enter only actual expenditures in this column.

Amount Requested for Reimbursement: Requested reimbursement.

I certify that the information provided in the Tribal Veterans Service Reimbursement Grant Worksheet for this grant is accurate. Grant funds shall be maintained in a separate account subject to audit by the Wisconsin Department of Veterans Affairs. I further agree to fully cooperate in any review and audit of grant expenditures by the department, including the provision of any relevant single audit document that establishes that grant funds previously received have been audited. I understand that pursuant to s. 45.47 Stats., if a county fails to comply with the above requirements, the Wisconsin Department of Veterans Affairs may, in addition to any other legal remedy available, reduce, suspend, or terminate the grant provided to the applicant. The person signing below this line must be a designated Tribal Council Official, authorized to certify the completed Tribal Veterans Service Reimbursement Grant Worksheet is complete and accurate.
Name:	Position:
Please print legibly
Phone Number:	( )	Email:
Signature:	Date:
Reimbursement check should be made payable to:
Payee:
Address:
C For WDVA Use Only.
Total amount requested for reimbursement: $ Total amount not approved:	$
Total amount approved for reimbursement:	$