HomeMy WebLinkAbout20152295.tiff COLORADO DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
COUNTY VETERANS SERVICE OFFICERS - MONTHLY REPORT AND CERTIFICATION OF PAY
COUNTY OF WELD MONTH OF JUNE 2015
SECTION I: GENERAL INFORMATION
Telephone Calls 339 Correspondence Received 71
Office (Public Contacts) 406 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 40 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 4
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
Non Service Connected Pension: VEAP CH 32
21-526 4 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 5 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 1 Other (Specify)
w/Accrued Benefits 1 A4.t-eJ CVA-''a (Ro„icpri R/9n111
1 e, , -i CPkf) 2015-2295
VA 000
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 w/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 7 Review
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
4 amount(s) for the month (of June 2015 Weld County
Salary Deo n &Cody 5,005
Expenses
Office Space
Telephone $ 259.23
Office Supplies
Travel
Training Conference
Other
Other
Total $ 5,264.23
- is
(Signature of County Veterans Service Officer) (Date)
SECTION IV: CERTIFICATION BY COUNTY COMMISSIONER OR DESIGNEE
In accordance with CRS 28-5-707, hereby certify the accuracy of the Report(CVA-26, revised 8/2011):
County Commissioner or Designee of
' Barbara Kir meyer, aCair
Weld County
cjuL 2 7 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)
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