HomeMy WebLinkAbout20123611.tiff COLORADO DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
COUNTY VETERANS SERVICE OFFICERS - MONTHLY REPORT AND CERTIFICATION OF PAY
COUNTY of: Weld Month of: November, 2012
SECTION 1: GENERAL INFORMATION
Telephone Calls 573 Correspondence Received 78
Office (Public Contacts) 222 Correspondence Written 86
Home Visits Information and Referral/Inquiries 110
Outreach Visits (i.e. NH...) 1 Other(i.e. VCAA Notice Response) 35
Community Events/Forums 2 State Benefitgs1 7
Request for Medals _ 3 Request for Military Records &Corrections
Operation Recognition SF-180 17
DD 149
Request for Medical Treatment Records DD 293
21-4142 [ 15 NA 13075
Other( )
SECTON II: NEW CLAIMS INITIATED
[Provide number of new claims initiated for current reporting month]
Ay ointed Representative: Death Pension I Widows Pension
21-22 CVA 31 21-534 1
21-22 Other w/Accrued Benefits
Claims for SC Entitlement: Request for VA Healthcare
21-526 (SC - New/) 29 10-10 EZ 28
21-4138 (SC - Informal Claim) 1 10-10 EZ-R 3
21-4138 (SC - New Issue) 2 10-583
21-4138 (SC - Reopen) 10-10d (CHAMPVA- Dependents)
21-4138 _(SC - Increase) 10-7959a (CHAMPVA)
21-4138 (SC -Sa-mdarytAiwaaa'.;n) 10-7959C (CHAMPVA- Insurance Cert
21-4138 (SC - Reinstatement)
21-4138 (SC wl IU) Vocational Rehabilitation
21-8940 (IU) 28-1900 CH 31
21-4192 (IU - Employer) 28-1900 (Independent Living Program)
21-4138 ,(SMC) ___
21-686c Educational Assistance Programs
POST 9/11 CH 33 8
Non Service Connected Pension: VRAP CH 32 5
21-526 2 VN Era GI CH 34
21-527 22-5490 CH 35 2
686c Sel Reservist NG CH 1607
21-526/527 WI A&A 21-674
21-4138 (Reinstatement)
EVR (Any) Miscellaneous Claims
21-8416 2 21-8678 (Clothing Allowance) 1
5655 _ 21-4502 (Auto Grant/Adaptive Equipment) 1
26-4555 (Housing Grant)
Request for Waivers/Compromise: 10-0103 (HISA Grant)
21-4138 Medicaid Application Assistance
5655 (FSR) SSA Application Assistance _
Other(Specify)
Dependent Indemnity Compensation (DIC) Other(Specify)
21-534 Other(Specify)
w/Accrued Benefits
CVA-26(Revised 9/1/2006)
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SECTION II (Continued):
Burial Allowance Claims for insurance
21-530 2 29-357
40-1330 4 29-4364
21-2008 29-336 (Designation of Beneficiary)
21-4125 (Claim for Lump Sum Payment) 2
VA Home Loan
26-1800 1 Requests wl VTF(Grant),#Vets Assisted
26-1817 Rental Assistance 3
Utilities Assistance 1
Homeless Veterans Claims Filed Prescription Assistance/Other Medical
SC 3 Food 12
NSC Transportation 10
Clothing
Incarcerated Veterans Other
21-4193 Release/Reinstatement 1
21-4138 (Apportionment)
Appeals DRO Election
NOD 2 Review 2
VA 9 Hearing
SECTION III: CERTIFICATION BY COUNTY VETERANS SERVICE OFFICER
I hereby certify, the above captioned monthly report is true and accurate. I have been paid the following
amount(s) for the month of November 2012
Salary $3,124.17
Expenses
Office Space
Telephone $280.65
Office Supplies
Travel
Training Conference
Other
Other
Total _ $3,404.82
2 -- 2-
(Sjgnatorriof County Veterans Service Officer) (Date)
SECTION IV: CERTIFICATION BY COUNTY COMMISSIONER OR DESIGNEE
In accordance with CRS 28-5-707, I hereby certify the accuracy of the Report(CVA-26, revised 9/1/2012011)
\ —'
C J County Commissioner or Designee of
Sean P. Conway, Chair
WELD L County
DE". 1 7 201? Date
This certification, submitted monthly, properly signed and executed, will be considered as application for the
monetary benefits to the County General Fund, in accordance with 28-5-804 (2002) Colorado Revised Statue.
This form is to be submitted by the 15th day of the following month. Mail to:
Colorado Division of Veterans Affairs
Attention: Director Bill Conroy
1355 S. Colorado Blvd., Suite 113, Bldg C
Denver, CO 80222 CVA-26(Revised 9/112006)
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