Wis. Stats. Chapter 45	2135 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387)
VETERAN'S RESIDENCY AFFIDAVIT
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.
Note: Affidavits with cross-outs, write-overs, white-out, correction tape, or any other correction material cannot be accepted. If an error is made you will need to complete a new form. You must submit the original, signed, and notarized document. Faxes, scans, or photocopies of this completed form cannot be accepted.

Eligibility for State of Wisconsin benefits offered under Ch. 45 Sections 45.02(2)(a-c) Wis. Stats., require an eligible veteran to either have been a resident of Wisconsin at the time of entry into active service or to have been a Wisconsin resident for any consecutive 12-month period after entry or reentry into service. Veterans and Surviving Spouses Property Tax Credit Section 71.07(6e)(a)3.b., Wis. Stats., requires an eligible veteran to either have been a resident of Wisconsin at the time of entry into active service or the national guard or reserve component of the U.S. armed forces or to have a consecutive 5-year period of Wisconsin residence after entry into that service.	Veteran’s Wisconsin
Department of Veterans
Affairs Base File #:
(if known)
Wisconsin G.I. Bill Section 36.37(3p)(a)1r. and Section 38.24(8)(a)1r., Wis. Stats., require an eligible veteran to either have been a resident of Wisconsin at the time of entry into active service or to have been a Wisconsin resident for at least 5 consecutive years immediately preceding the beginning of any semester or session for which the person registers at a participating institution.
Veteran's Name:
Current Address:	Phone Number:
Street Address
Apt. Unit #	E-mail Address:
City State Zip Code
Veteran's Social Security Number:
Part 1
Veteran's State of Legal Residency at Time of Entry Into Active Service and Date of Entry Into Active Service:
State of Legal Residency	Date of Entry
Veteran's Address at Time of Entry Into Active Service:
Street Address
Apt. Unit #
City State Zip Code

Part 2 Complete Part 2 only if veteran was not a legal resident of Wisconsin at time of entry into active service. Eligibility for state of Wisconsin benefits offered under Ch. 45 Sections 45.02(2)(a-c) Wis. Stats., require an eligible veteran to either have been a resident of Wisconsin at the time of entry into active service or to have been a Wisconsin resident for any consecutive 12-month period after entry or reentry into service.
Veterans and Surviving Spouses Property Tax Credit Section 71.07(6e)(a)3.b., Wis. Stats., requires an eligible veteran to either have been a resident of Wisconsin at the time of entry into active service or the national guard or reserve component of the U.S. armed forces or to have a consecutive 5-year period of Wisconsin residence after entry into that service. Wisconsin G.I. Bill Section 36.37(3p)(a)1r. and Section 38.24(8)(a)1r., Wis. Stats., require an eligible veteran to either have been a resident of Wisconsin at the time of entry into active service or to have been a Wisconsin resident for at least 5 consecutive years immediately preceding the beginning of any semester or session for which the person registers at a participating institution.
Address 1:	Years Resided:
Street Address	From:
Month Year
Apt. Unit #	To:
Month Year
City State Zip Code

Address 2:	Years Resided:
Street Address	From:
Month Year
Apt. Unit #	To:
Month Year
City State Zip Code
Address 3:	Years Resided:
Street Address	From:
Month Year
Apt. Unit #	To:
Month Year
City State Zip Code
Address 4:	Years Resided:
Street Address	From:
Month Year
Apt. Unit #	To:
Month Year
City State Zip Code
(Attach additional pages if needed)

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
STATE OF WISCONSIN	)
ss.)
County of	)
On,	, before me, a Notary Public, appeared
who proved to me to be the person whose name is subscribed in this document and acknowledged to me that he/she executed the same in his/or her official capacity and that his/her signature on the instrument the person executed the instrument.
Subscribed and sworn to before me this	day of	, 20
Notary Public
My Commission Expires:

For WDVA Use Only
Acceptable Original?	Yes	No
Reason:
Reviewed By:	Date: