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COLORADO DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
COUNTY VETERANS SERVICE OFFICERS - MONTHLY REPORT AND CERTIFICATION OF PAY
COUNNTY OF WELD MONTH OF SEPTEMBER 2014
SECTION I: GENERAL INFORMATION
Telephone Calls I 392 Correspondence Received 65
Office (Public Contacts) 406 Correspondence Written
Home Visits Information and Referral/Inquiries 60
Outreach Visits (i.e. NH...) 1 Other(i.e: VCAA Notice Response)
Community Events/Forums State Benefit(s)
Request for Medals 4 Request for Military Records & Corrections
Operation Recognition SF-180 8
DD 149 1
Request for Medical Treatment Records DD 293 1
21-4142 I 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 J 40 21-534 2
21-22 Other wl Accrued Benefits 1
Claims for SC Entitlement: Request for VA Healthcare
21-526 (SC - New/) 15 10-10 EZ 14
21-4138 (SC - Informal Claim) 3 10-10 EZ-R 2
21-4138 (SC - New Issue) 22 10-583
21-4138 (SC - Reopen) — 10 10-10d (CHAMPVA - Dependents)
21-4138 (SC - Increase) 10-7959a (CHAMPVA)
21-4138 (SC - Seconcery,Aigrava^c) 10-7959C (CHAMPVA - Insurance Cert
_
21-4138 (SC - Reinstatement)
21-4138 (SC wl IU) Vocational Rehabilitation
21-8940 (IU) 28-1900 CH 31
21-4192 (IU - Employer) _ 28-1900 (Independent Living Program)
21-4138 (SMC) _ _
21-686c 2 Educational Assistance Programs
MGIB CH 30
Non Service Connected Pension: VEAP CH 32
21-526 _ VN Era GI CH 34
21-527 22-5490 CH 35
686c Sel Reservist NG CH 1607
21-526/527 w/A&A _ 21-674
21-4138 (Reinstatement)
EVR (Any) Miscellaneous Claims
21-8416 21-8678 (Clothing Allowance) 1
--I
5655 - 21-4502 (Auto Grant/Adaptive Equipment) 1
26-4555 (Housing Grant)
Request for Waivers/Compromise: 10-0103 (HISA Grant)
21-4138 Medicaid Application Assistance
5655 (FSR) - SSA Application Assistance
Other(Specify)
1 rl-nal 1 5f 2014-3512
//�l 0-201 1 VA 11-10-q- VA OOO1
Dependent Indemnity Compensation (DIC) Other (Specify)
21-534 2 Other (Specify)
w/Accrued Benefits
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
26-1800 1 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 4 Review
VA 9 2 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 of _SEPTEMBER 2014 County of Weld
Salary $4,894.00
Expenses
Office Space
Telephone 243.62
Office Supplies
Travel
Training Conference
Other
Other
Total 5140.62 l?C\ 1
(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 9/1/2(2011)
County Commissioner or Designee of
Weld County
NOV 1 0 2014 Date
This certification, submitted monthly, properly signed and executed, will be considered as application for the
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