HomeMy WebLinkAbout20160385.tiff ,.. COLORADO DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
COUNTY VETERANS SERVICE OFFICERS - MONTHLY REPORT AND CERTIFICATION OF PAY
COUNTY OF WELD MONTH OF DECEMBER 2015
SECTION I : GENERAL INFORMATION
Telephone Calls 380 Correspondence Received 71
Office ( Public Contacts) 411 Correspondence Written 65
Home Visits Information and Referral/Inquiries
Outreach Visits ( i . e. NH . . . ) Other ( i . e : VCAA Notice Response)
Community Events/Forums 2 State Benefit(s) 1
Request for Medals 2 Request for Military Records & Corrections
Operation Recognition SF- 180 18
DD 149
Request for Medical Treatment Records DD 293
21 -4142 [ NA 13075
Other (
SECTON II : NEW CLAIMS INITIATED
[Provide number of new claims initiated for current reporting month]
Appointed Representative : Death Pension / Widows Pension
21 -22 CVA 44 21 -534 2
21 -22 Other w/ Accrued Benefits
I
Claims for SC Entitlement: Request for VA Healthcare
21 -526 (SC - New/) 10 10- 10 EZ 8
21 -4138 (SC - Informal Claim ) 1 10- 10 EZ-R
21 -4138 (SC - New Issue) 15 10-583
21 -4138 (SC - Reopen ) 10- 10d (CHAMPVA - Dependents)
21 -4138 (SC - Increase) 13 10-7959a (CHAMPVA)
21 -4138 (SC - Secondary/Aggravation) 10-7959C (CHAMPVA - Insurance Cert
21 -4138 (SC - Reinstatement)
21 -4138 (SC w/ IU ) Vocational Rehabilitation
21 -8940 ( IU ) 28- 1900 CH 31
• 21 -4192 ( IU - Employer) 1 28- 1900 ( Independent Living Program )
21 -4138 (SMC )
21 -686c Educational Assistance Programs
MGIB CH 30 3
Non Service Connected Pension : VEAP CH 32
21 -526 1 VN Era GI CH 34
21 -527 3 22-5490 CH 35
686c 1 Sel Reservist NG CH 1607
21 -526/527 w/ A&A 3 21 -674
21 -4138 ( Reinstatement)
EVR (Any) Miscellaneous Claims
21 -8416 21 -8678 (Clothing Allowance)
5655 21 -4502 (Auto Grant / Adaptive Equipment)
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 4 Other (Specify) 2016-0385r
w/ Accrued Benefits 3 ./eitt-b->
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( Revised 8/2011 )
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SECTION II (Continued ) :
Burial Allowance Claims for Insurance
21 -530 1 29 -357
40- 1330 29-4364
21 -2008 29-336 ( Designation of Beneficiary)
21 -4125 (Claim for Lump Sum Payment)
VA Home Loan
26- 1880 (Certificate of Eligibility) 5 Requests wl VTF (Grant) , # Vets Assisted
26- 1817 Rental Assistance
Utilities Assistance
Homeless Veterans Claims Filed Prescription Assistance / Other Medical
SC Food
NSC Transportation
Clothing
Incarcerated Veterans Other
21 -4193 Release/Reinstatement 1
21 -4138 (Apportionment)
Appeals DRO Election
NOD 7 Review 5
VA 9 3 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 December 2015 Weld County
Salary Deo n &Wendy 6 , 200
Expenses
Office Space
Telephone $ 241 . 78
Office Supplies
Travel
Training Conference
Other
Other
Total $6 , 441 . 17
PA3V\
(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 ) :
County Commissioner or Designee of
Mike Freeman , Chair
Weld County
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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 (2lb
Denver, CO 80222 CVA-26 ( Revised 8/2011 )
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