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es COLORADO DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
COUNTY VETERANS SERVICE OFFICERS - MONTHLY REPORT AND CERTIFICATION OF PAY
COUNTY OF WELD MONTH OF APRIL 2017
SECTION I: GENERAL INFORMATION
Telephone
Calls
676
Office (Public Contacts)
447
Home Visits
Outreach Visits (i.e. NH...)
Community Events/Forums
_ 1
Request for Medals
1
Operation Recognition
Request for Medical Treatment Records
21-4142
11
Correspondence
Received
71
Correspondence
Written
85
Information
and Referral/Inquiries
Other (i.e: VCAA Notice Response)
State Benefit(s)
4
Request for Military Records & Corrections
SF -180
23
DD 149
2
DD 293
3
NA 13075
Other )
SECTON II: NEW CLAIMS INITIATED
[Provide number of new claims initiated for current reporting month]
Appointed
Representative:
21-22
CVA
53
21-22
Other
Claims for SC Entitlement:
21-526
;(SC - New/)
41
21-4138
(SC - Informal Claim)
32
21-4138
(SC - New Issue)
21-4138
(SC - Reopen)
21-4138
(SC - Increase)
21-4138
(SC - S Matto„)
21-4138
(SC - Reinstatement)
21-4138
(SC At/ IU)
21-8940
(IU)
21-4192
(IU - Employer)
7
21-4138
(SMC)
21-686c
4
Non Service Connected Pension:
21-526
2
21-527
3
686c
4
21-526/527 w/ A&A
5
21-4138 (Reinstatement),
EVR (Any/
21-8416
5655
Request
for Waivers/Compromise:
21-4138
5655 (FSR)
Dependent Indemnity Compensation (DIC)
21-534
2
w/ Accrued Benefits
Death Pension / Widows Pension
21-534
2
w/ Accrued Benefits
Request
for VA Healthcare
10-10 EZ
9
10-10 EZ-R
2
10-583
10-10d (CHAMPVA - Dependents)
3
10-7959a (CHAMPVA) -
10-7959C CHAMPVA - Insurance Cert
Vocational Rehabilitation
28-1900 CH 31
2
28-1900 (Independent
Living Program;
Educational Assistance Programs
MGIB
CH 30
VEAP
CH 32
VN Era GI
CH 34
22-5490
CH 35
Sel Reservist NG CH 1607
L21-674
Miscellaneous Claims
21-8678 (Clothing Allowance)
21-4502 (Auto Grant / Adaptive
Equipment)
26-4555 (Housing Grant)
10-0103 (HISA Grant)
Medicaid Application
Assistance
SSA Application
Assistance
Other (Specify)
Other (Specify]
Other (Specify)
CVA-26 (Re 812011)
/-1/443 o/si i 000
5�� t
SECTION II (Continued):
Burial Allowance
21-530
4
40-1330
5
21-2008
2
VA Home Loan
26-1880 (Certificate of Eligibility)
2
26-1817
Homeless Veterans Claims Filed
SC
NSC
Incarcerated Veterans
21-4193 Release/Reinstatement
21-4138 (Apportionment)
Appeals
NOD
7
VA 9
3
Claims for Insurance
29 -357
29-4364
29-336 (Designation of Beneficiary)
21-4125 (Claim for Lump Sum Payment)
Requests w/ VTF (Grant), # Vets Assisted
Rental Assistance
Utilities Assistance
Prescription Assistance / Other Medical
Food
Transportation
Clothing
Other
DRO Election
Review
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 c of April 2017 Weld County
Salary Deo n & Wendy
Expenses
Office Space
Telephone
Office Supplies
Travel
Training Conference
Other
Other
Total
$7,300.00
$ 257.68
$ 7,557.68
5 \s C\
(Signature of 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 8/2011):
Julie A. Cozad, :ir
Weld
MAY 3 1 20;7
County Commissioner or Designee of
County
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 c2.0/
Denver, CO 80222 CVA-26 (Revised 8/2011)
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