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COLORADO DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
COUNTY VETERANS SERVICE OFFICERS - MONTHLY REPORT AND CERTIFICATION OF PAY
COUNTY OF WELD MONTH OF SEPTEMBER 2016
SECTION I: GENERAL INFORMATION
Telephone Calls
608
Office (Public Contacts)
574
Home Visits
Outreach Visits (i.e. NH...)
1
Community Events/Forums
1
Request for Medals
2
Operation Recognition
21
Request for Medical Treatment Records
-4142
5
Correspondence Received
85
Correspondence Written
80
Information and Referral/Inquiries
Other (i.e: VCAA Notice Response)
State Benefit(s)
Request for Military Records & Corrections
SF -180
DD 149
DD 293
NA 13075
Other (_
5
SECTON II: NEW CLAIMS INITIATED
[Provide number of new claims initiated for current reporting month]
Appointed Representative:
21-22 ]CVA
43
21-22 Other
Claims for SC Entitlement:
21-526
(SC - New/)
34
21-4138
(SC - Informal Claim)
23
21-4138
(SC - New Issue)
21-4138
(SC - Reopen)
21-4138
(SC -Increase)
21-4138
(SC - Secondary/Aggravation)
21-4138
(SC - Reinstatement)
21-4138
(SC w/IU)
21-8940
(IU)
21-4192
(IU - Employer)
21-4138
(SMC)
21-686c
5
Non Service Connected Pension:
21-526
21-527
5
686c
21-526/527 w/ A&A
21-4138 (Reinstatement)
EVR (Any)
21-8416
5655
Request for Waivers/Compromise:
21-4138
5655 (FSR)
Dependent Indemnity Compensation
(DIC)
2
21-534
w/ Accrued Benefits
2
Death Pension / Widows Pension
21-534
w/ Accrued Benefits
Request for VA Healthcare
10-10 EZ
10
10-10 EZ-R
1
10-583
10-10d (CHAMPVA - Dependents)
10-7959a (CHAMPVA)
10-7959C (CHAMPVA - Insurance Cert
Vocational Rehabilitation
28-1900 CH 31
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
21-674
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
_
—
_
I 1
Other (Specify) 2016-3430
Other (Specify)
Other (Specify) 1/ A.
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CVA-26 (Revised 9/12006)
SECTION II (Continued):
Burial Allowance
21-530 _
40-1330
21-2008
2
VA Home Loan
26-1800
26-1817
1
Homeless Veterans Claims Filed
SC
NSC
Incarcerated Veterans
21-4193 Release/Reinstatement
21-4138 (Apportionment)
Appeals
NOD
VA 9
Claims for Insurance
29 -357
29-4364
29-336 (Designation of Beneficiary)
21-4125 (Claim for Lump Sum Payment)
Requests WI VTF (Grant), # Vets Assisted
Rental Assistance
Utilities Assistance
Prescription Assistance / Other Medical
Food
Transportation
Clothing
Other
DRO Election
Review
Heari
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 SEPTEMBER 2016
Salary $6,400.00
Expenses
Office Space
Telephone $257.51
Office Supplies
Travel
Training Conference
Other
Other
Total
c
$6,657.51
(Signature of County Veterans Service Officer)
/0 / 5—/.6
(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 9/1/20(2011)
1 �K� County Commissioner or Designee of
Mike Freeman, Chair
Weld County
NOV 01 2016
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/6
Denver, CO 80222 CVA-26 (Revised 9/1/2006)
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