WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10162 (07/08)
VERIFICATION OF VETERANS BENEFITS
All shaded areas to be completed by the local county or tribal agency. Once the shaded areas are completed, mail this form to: Department of Veteran Affairs 5400 West National Milwaukee, WI 53214 Or, you may call 1-800-827-1000 Applicant Name Applicant Social Security Number CARES Case Number Veteran Name Veteran Social Security Number or Veteran File Number Date of Request
The following sections are to be completed by Veterans Affairs. Once completed, please return this form to the local agency at:
Type of benefits veteran is receiving?
Is any portion of this benefit apportioned out to a dependent? If yes, what is the amount apportioned? $
Enter the amount of benefit received for each of the months listed below. If no months are listed, use the last three months. Month Received Aid and Attendance (A & A) $ $ $ Housebound Allowance $ $ $ Yes No Unusual Medical Expense $ $ $ Total of all Benefits $ $ $
Are any of the Veterans benefits withheld for any reason?
What is the month and year the veteran began receiving benefits? Since the last yearly increase, has there been a change in Veterans benefits? If yes, in which month and year was the change? What is the reason for this change? Additional Comments Yes No
SIGNATURE Person Providing Information Telephone Number
Title Date Signed