HomeMy WebLinkAbout20154057.tiff COLORADO DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
COUNTY VETERANS SERVICE OFFICERS -MONTHLY REPORT AND CERTIFICATION OF PAY
COUNTY OF WELD MONTH OF NOVEMBER 2015
SECTION I: GENERAL INFORMATION
Telephone Calls 454 Correspondence Received 80
Office(Public Contacts) 464 Correspondence Written 75
Home Visits Information and Referral/Inquiries
Outreach Visits(i.e. NH...) Other(i.e: VCAA Notice Response)
Community Events/Forums 2 State Benefit(s) 2
Request for Medals 2 Request for Military Records&Corrections
Operation Recognition SF-180 11
DD 149 2
Request for Medical Treatment Records DD 293 1
21-4142 I 1 NA 13075
Other( )
SECTON II: NEW CLAIMS INITIATED
[Provide number of new claims initiated for current reporting month]
Ap ointed Representative: Death Pension/Widows Pension
21-22 CVA 44 21-534 2
21-22 Other w/Accrued Benefits 1
Claims for SC Entitlement: Request for VA Healthcare
21-526 (SC-New/) 10 10-10 EZ 12
21-4138 (SC- Informal Claim) 8 10-10 EZ-R
21-4138 (SC-New Issue) 15 10-583
21-4138 (SC- Reopen) 3 10-10d (CHAMPVA-Dependents) 1
21-4138 (SC-Increase) 10 10-7959a (CHAMPVA)
21-4138 (SC-secondary/Aggravation) 10-7959C (CHAMPVA-Insurance Cert 1
21-4138 (SC- Reinstatement)
21-4138 (SC w/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
MGIB CH 30
Non Service Connected Pension: VEAP CH 32
21-526 2 VN Era GI CH 34
21-527 3 22-5490 CH 35
686c 1 Sel Reservist NG CH 1607
t 21-526/527 w/A&A 5 21-674
21-4138(Reinstatement)
EVR(Any) Miscellaneous Claims
r 21-8416 21-8678 (Clothing Allowance)
5655 21-4502 (Auto Grant/Adaptive Equipment)
26-4555 (Housing Grant)
f' 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 1 Other(Specify)
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SECTION II (Continued):
Burial Allowance Claims for Insurance
21-530 2 29-357
40-1330 1 29-4364
21-2008 1 29-336(Designation of Beneficiary)
21-4125(Claim for Lump Sum Payment)
VA Home Loan
26-1880(Certificate of Eligibility) 2 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
21-4138 (Apportionment)
Appeals DRO Election
NOD 2 Review
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 c of NOV 2015 Weld County
Salary Deoo n &Wendy 5,024
Expenses
Office Space
Telephone $ 255.28
Office Supplies
Travel
Training Conference
Other
Other
Total $ 5,279.28
..(26)C\ 12 - 15.- /S
(Signature of County Veterans Service Officer) (Date)
SECTION IV: CERTIFICATION BY COUNTY COMMISSIONER OR DESIGNEE
In accordance wit CRS 28-5-70 , hereby certify the accuracy of the Report(CVA-26, revised 8/2011):
V County Commissioner or Designee of
7
Weld County
DEC 3 0 2015 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 8/2011)
p0/5_ 9067
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