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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 October 2015
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SECTION I : GENERAL INFORMATION
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Telephone Calls 372 Correspondence Received 85
Office (Public Contacts) 404 Correspondence Written 80
Home Visits Information and Referral/Inquiries a
Outreach Visits ( i . e. NH . . . ) 1 Other (i . e: VCAA Notice Response)
Community Events/Forums 1 State Benefit(s) 2
Request for Medals Request for Military Records & Corrections
. Operation Recognition SF- 180 18
DD 149 1
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Request for Medical Treatment Records DD 293 2
21 -4142 1 4 NA 13075
0 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 wl Accrued Benefits 1
Claims for SC Entitlement: Request for VA Healthcare
21 -526 (SC - New/) 20 10- 10 EZ 15
21 -4138 (SC - Informal Claim) 4 3 10- 10 EZ-R
21 -4138 (SC - New Issue) 22 10-583
21 -4138 (SC - Reopen) 12 10- 10d (CHAMPVA - Dependents) 1
21 -4138 (SC - Increase) 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) . 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 VN Era GI CH 34
21 -527 8 22-5490 CH 35
686c 2 SeI Reservist NG CH 1607
21 -526/527 w/ A&A 21 -674
21 -4138 ( Reinstatement)
EVR (Any) Miscellaneous Claims
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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 2 Medicaid Application Assistance
I 5655 (FSR) 1 SSA Application Assistance
Other (Specify)
2015-3679
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Dependent Indemnity Compensation (DIC) Other (Specify) I
21 -534 IOther (Specify) I
wl Accrued Benefits
SECTION 11 (Continued ) :
Burial Allowance Claims for Insurance
21 -530 1 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
26-1800 I 5 Requests wl VTF (Grant), # Vets Assisted
•26-1817 Rental Assistance
Utilities Assistance
Homeless Veterans Claims Filed Prescription Assistance / Other Medical
FSC l Food
NSC I Transportation
Clothins
Incarcerated Veterans Other
21 -4193 Release/Reinstatement l
21 -4138 (Apportionment)
Appeals DRO Election
NOD I 21I Review
Hearing I 11
IVA 9
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 Oct-15 COUNTY OF WELD
Salary $6, 200. 00
Expenses
Office Space
Telephone 239. 14
Office Supplies
Travel
Training Conference
Other
Other
Total 6,439. 14
k 9,62i ry.c,_-- / / /orts
(Signature of County Veterans Service Officer) (Date)
SECTION IV: CERTIFICATION BY COUNTY COMMISSIONER OR DESIGNEE
In accordance with CRS 28-5-707, I h reby certify the accuracy of the Report (CVA-26, revised 9/1 /2( 2011 )
/61(Stet � County Commissioner or Designee of
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eld County
NOV 1 8 z015 Date
This certification , submitted monthly, properly signed and executed , will be considered as application for the
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