HomeMy WebLinkAbout55-18 - Res. Amending Res. 22-17 Veterans Advisory Board Removal of Driver License Reinstatement RESOLUTION NO. 55 -1 S
A RESOLUTION AMENDING RESOLUTION NO. 22-17
VETERANS ADVISORY BOARDNETERANS' ASSISTANCE
Removal of driver license reinstatement
WHEREAS, Mason County established a levy per RCW 73.08.080 for the purpose of creating
the Veterans'Assistance Fund for the relief of honorably discharged veterans or for veterans
discharged for physical reason with an honorable record;
WHEREAS, RCW 73.08.035 authorizes the establishment of a Veterans' Advisory Board;
WHEREAS,the Mason County Commissioners adopted Resolution No. 58-13 establishing the
Veterans Advisory Board (VAB). The VAB will consist of ten members;
two appointed members of each of the following Mason County National Veterans' Organizations:
American Legion, Veterans of Foreign Wars, 40 et 8 and Disabled American Veterans and two Mason
County resident Veterans.
WHEREAS, RCW 73.08.010 provides for the relief of indigent and suffering veterans and their
families or the families of those deceased veterans, who need assistance and on April 25, 2017 the
annual cash award was increased to $1,200 per eligible veteran, the burial assistance was increased
to $1,000 and the catastrophic award to $1,000.
WHEREAS, the VAB has requested to delete the reinstatement of a driver license as an
eligible expense.
NOW, THEREFORE BE IT RESOLVED by the Board of Mason County
Commissioners that:
1. The Veterans'Assistance Fund may be disbursed to indigent veterans and their families or the
families of those deceased in the amounts not to exceed one thousand two hundred dollars
($1,200) per year.
2. Approval of the $1,200 dollar assistance shall be granted for only past due rent, mortgage, or
utilities:
a. Utilities include electric, water, firewood, wastewater(sewer), natural gas and/or
propane.
b. Necessity Items (Attachment R in Operating Policy) (Not to include tobacco and
alcoholic beverages).
c. Obtain State ID card (one time only).
3. Veteran Assistance funds shall not duplicate other available assistance for the purposes
stated in#2.
4. If any Veterans'Assistance Committee determines an applicant is in need of assistance due to
any event, catastrophic illness or other significant change in circumstance which comes into
being unexpectedly and is beyond the applicant's management or control, the Committee may
request in writing that Mason County consider approval of an amount not to exceed a one
thousand ($1,000.00) dollar lifetime limit per applicant.
J:\Veterans\Resolutions\Resolution-no drivers license reinstatement.docx
Resolution No.
Page 2 of 2
5. All requests for funding shall be approved by the Veterans'Service Officer and Mason County.
Mason County staff who are authorized signers on the Veterans'Assistance Bank Account are
authorized to issue assistance checks to qualified veterans without prior Commission
approval. Those checks issued will be reported to the Commissioners.
6. RCW 41.04.005 and other provisions of RCW Title 73 shall govern eligibility assistance to
veterans and/or families.
7. The County defines"indigent and suffering"to mean the current poverty level as defined by the
United States Department of Health and Human Services, for a period of time: previous 90
days or average of previous year.
8. As per RCW 73.08.070, the County shall assist indigent veterans with burial or cremation
costs of($300.00) minimum or up to one thousand ($1,000) dollars. This is in addition to the
$1,200 dollar limitation above in#2.
9. If any applicant knowingly and or unknowingly defrauds or provides false or misleading
information, or misuses funds, the applicant will be barred from receiving any further
assistance.
The entire Veterans'Advisory Board Operating Policy& Procedures is adopted as Attachment A
These amendments are adopted August 21, 2018 and effective September 1, 2018.
ATTEST: BOARD OF COUNTY COMMISSIONERS
MASON COUNTY,WASHINGTON
Melis a ry, Clerk the Board 4 X�
Ra dy Neatherlin , Chair
APPROVED AS TO FORM: 1, Z"-CL
Terri Drexler, Cordmissioner
Tim Whitehead, Chief DPAK,9--- VP
Kevin Shu C
, omm' sioner
c: Auditor
Nw VAB
J:\Veterans\Resolutions\Resolution-no drivers license reinstatement.docx
MASON COUNTY
VETERANS' ADVISORY BOARD
OPERATING POLICY &
PROCEDURES
The Mason County Veterans'Advisory Board submitted amendments to the Veterans'
Assistance Operating Policy in July 2018..
These Amendments are adopted by the Board of Mason County Commissioners this 21st day
of August, 2018 and effective September 1, 2018
Mason County,Washington
------ -- -- ----- ---------------------
Randy Neatherlin,Chair
---��w--------------------
ATTEST: Kevin Shutty,Commissioner
i
M lissa rewry, Cler of the Board Terri Drexler,Commissioner
MASON COUNTY
VETERANS' ADVISORY BOARD
OPERATING POLICY &
PROCEDURES
TABLE of CONTENTS
I. Organizational Policies.............................................................................................................................. 3
II. Financial Policies....................................................................................................................................... 3
III. Policy Establishing Board......................................................................................................................... 4
IV. Eligibility Policies.....................................................................................................................................4
V. Referral to Other Services........................................................................................................................ 5
VI. Appeal and Resolution Policy.................................................................................................................. 5
VII.Application Procedures.......................................................................................................................... 6
VIII. Processing of Packet Procedures .......................................................................................................... 7
IX. Records, Files, Forms and Reports .......................................................................................................... 7
X. List of Attachments (Att.) ......................................................................................................................... 8
Page 2 of 8
Adopted 08/21/2018
1. Organizational Policies
a. All RCWs (Revised Code of the State of Washington)within Chapter 73.08 RCW VETERAN'S
RELIEF,with other RCWs and Mason County Resolutions will be used and
referred to throughout this policy.
b. The purpose of the Mason County Veteran's Assistance Fund(VAF) is to provide relief as set forth
in RCW 73.08.010 to indigent and suffering veterans,their families and the families of deceased
indigent veterans.
c. Any honorably discharged veterans or veterans with a General Discharge under honorable
conditions or a General Discharge with other than honorable conditions (Administrative
Discharge),as outlined in RCW 41.04.005 and RCW 41.04.007,and meeting the criteria in I-b may
apply.
d. These policies and procedures are subject to review annually by the VAB.
1) If a revision is made,it is so noted and a narrative of revision is put in VAB minutes.
2) If no revisions are made,the date of review is noted,and put in VAB minutes.
3) Post Commanders will be advised concerning any revisions and reviews recommended by the
VAB.
4) MCC has final approval of all revisions.
e. The VAB will meet the second Wednesday of each month at 10:00am at the Memorial Hall on 2nd.
and Franklin St.,in Shelton,WA.
f. A quorum must be met to conduct any business that may come before the board.
g. If a quorum is not met,the Chair may contact other members via phone/text messaging or by e-
mail.
h. Upon reaching a member,and member agrees to be part of the meeting,thus creating
a quorum,the Chair must remain in contact with the member throughout the meeting.
II. Financial Policies
a. The funds for creating a Veterans'Assistance Fund (VAF) RCW 73.08.080,is
generated from a tax levied by the Mason County Commissioners(MCC),use of the fund is
governed by same RCW.
b. Approval of the one thousand two hundred($1,200) dollars for assistance shall be granted only
for the following:
1) Past Due Rent or Mortgage
2) Past Due Utilities:
i. Electric
ii. Water
iii. Natural Gas
iv. Wastewater(sewer)
3.) Miscellaneous Items:
i. Necessity Items(refer to list-Attachment A)
a. Single$150.00
b. Married$200.00
c. +$50.00 per dependent
ii. Needed Fire Wood or Propane
4) Other Items
i. Obtain state ID card(one time only)
d. Exclusions will include,but not limited to alcohol,tobacco,lottery tickets.
e. Purchases in excess of the amount written on the check are the responsibility of the applicant.
f. No cash back will be given to the applicant if purchases are less than the amount written on the
check.
g. All requests for assistance will be approved by the Veterans Service Officer(VSO),with final
approval by the MCC.
Page 3 of 8
Adopted 08/21/2018
h. If it is determined an applicant is in need of assistance due to any event,catastrophic illness or
other significant change in circumstance which comes into being unexpectedly and is beyond the
applicants'management or control,the VSO may request in writing that Mason County consider
approval of an amount not to exceed a one thousand ($1,000.00) dollar lifetime limit per applicant.
i. The intent of the VAF is not to replace assistance from any other agency,and assistance is granted
on a"Case by Case"basis only.
j. The VAF is not intended to provide continuing assistance on a routine basis.
k. The VAF shall not duplicate other available assistance for the purposes as noted in Il.(c)
III. Policy Establishing Board
a. RCW 73.08.035 states each county must establish a Veteran's Advisory Board(VAB),the board
shall advise MCC on the needs of local indigent veterans,the resources available to local indigent
veterans,and programs that could benefit the needs of local indigent veterans and their families.
b. The VAB is comprised of veterans from the community"at large",and representatives from
nationally recognized veterans'service organizations within Mason County.Per said RCW,no
fewer than a majority of the board members shall be members from a nationally recognized
veterans'service organization and only veterans are to serve on the board. Service on the board is
voluntary.
c. Mason County Resolution NO.05-15 allows for appointment of two members residing in Mason
County from each Nationally Recognized Veterans'Service Organizations to be appointed to the
Veteran's Advisory Board (VAB),and two members"at large".
d. The VAB will consist of a ten(10)member board;members are appointed as follows:
1) American Legion(2 members)
2) Veterans of Foreign Wars (2 members)
3) 40 et 8 (2 members)
4) Disabled American Veterans(2 members)
5) Two (2) Mason County resident veteran(at large)
e. Commanders of these organizations will not be members of the VAB.
f. Commanders will appoint the members from their organization to serve on the VAB for the
purpose of overseeing the VAF.
g. These members may be appointed or removed at the discretion of their commander.
h. The first appointment of members shall be three (3)members for a three(3)year term,and four
(4)members for a two(2)year term.
i. Thereafter all terms will be two (2)year terms.
j. The MCC reserves the right to disallow VAB appointee for cause.
IV. Eligibility Policies
a. RCW 73.08.005 and other provisions in RCW Title 73 shall govern eligibility assistance to indigent
and suffering veterans and/or families.
b. The county defines"indigent and suffering"to mean the current poverty level as defined by the
United States Department of Health and Human Services.(HHS) (Att.B)
c. Family members entitled to apply for assistance shall be defined as spouse or domestic partner,
surviving spouse or surviving domestic partner,and dependent children of a living or deceased
veteran.
d. Applicants must be a resident of the Mason County for at least ninety(90) days.
e. Applicant must present proof of residency and income.
f. An applicant may use hotel/motel receipts as proof of residence,provided that:
Page 4 of 8
Adopted 08/21/2018
1) All receipts show a minimum of a 90 (ninety)day stay with in Mason County.
2) The 90 (ninety)day stay must be continuous.
3) All receipts must be in the applicant's name.
4) All receipts must be original(no copies).
g. Under the federally-established poverty guidelines,the gross income of the veteran and all
members of the household must be at or below150%of the poverty guidelines established by the
HHS(Att.B).
h. Veterans making above the 150%and who do not have an emergency financial situation will not be
eligible for assistance.
i. An applicant may have a source of income above the aforementioned 150%and still be considered
indigent on an emergency basis.
j. Lack of funds because of bad financial management of an adequate source of income does not
make the applicant indigent
V. Referral to Other Services
a. As per RCW 73.08.070 the county shall assist indigent veterans with burial or cremation costs of
three hundred($300.00) dollars minimum or up to one thousand($1,000)dollars.
b. The burial assistance is in addition to prior twelve hundred thousand($1,200.00)dollars
limitation as outlined in II-c.
c. In an effort to maximize dollars and provide for as many as possible applicants,and
when appropriate,the veteran may be referred by the VSO to other veteran services
and to other community resources for services.
VI. Appeal and Resolution Policy
a. If an applicant has either by accident or on purpose falsely filed a claim,or has misused monies
from the Veterans'Assistance Fund,the following will apply:
1) A letter is given to the applicant,from the County,denying further use of this fund,until the
false claim is resolved.
2) A copy of that letter will be sent to the Veterans'Service Office,to be placed in the offending
applicant's file.
3) The applicant's file will then be"Red Flagged",and denied further use until the problem is
resolved.
b. To resolve the claim,the applicant can clear their name by:
1) If applicant feels this is unjustified,they may appeal in writing to the Veterans'Advisory Board
within fifteen (15) days of notification.
2) The appeal will be reviewed by the VAB at the next regular scheduled meeting and a decision
will be made no later than the next regular scheduled meeting.
3) Approval or Disapproval requires a"Super Majority"vote by the entire VAB.
4) The applicant may file an appeal,in writing,with the Mason County Commissioners.A decision
in regard to appeal may take up to 30 days.
c. The applicant may repay any and all monies that have come into question,and may not have access
to these funds for one(1)year after payment.
d. If the applicant elects not to do VI.b.or VI.c.there will be a two(2)year probationary wait period.
After the wait period is over,the applicant must"in writing"request to receive these funds once
more,a decision will be forthcoming.
Page 5 of 8
Adopted 08/21/2018
e. If it is found that the applicant has done this two (2) times,they will be permanently denied from
using this fund.
VII. Application Procedures
a. Upon arriving at the VSO office the applicant will be asked to sign-in.
b. The applicant is then screened about their assistance needs,residence,income,and their
eligibility,an"Assistance Fund Application(AFA) (Att.C)and a Rental/Mortgage Verification"(Att.
D)form must be filled out as part of the application process.
c. If the applicant does not have all needed information or documentation,they will be given a form
"Veterans'Assistance Fund Documents Checklist"(Att E) to help them gather the needed
information and return form to VSO.
d. If an applicant cannot show proof of service,a"Standard Form 180" (Att.F)will be given to them to
be filled out and sent in,they can also go to the VA at American Lake to get proof of service.
e. If two or more applicants are sharing the same physical residency,then all income is considered as
one.
f. Only one application may be used for any single physical residency.
g. If an applicant has a"Sub-Lease Agreement",then VII (j)will apply.
h. When an applicant has requested assistance for past due rent or mortgage payment,II. (c)(1), and
has gone through the screening process.The VSO will call the landlord to inform them that the
veteran has applied for assistance,and that a letter of "Recommendation for Payment" (Att.G)will
be forthcoming.
i. The applicant will then be given a form"Rental/Mortgage Verification" (Att.D)to be given to the
landlord.This form must be filled out by the landlord or lien holder,notarized and sent back or
taken to the VSOs' office.The VSO will then verify all information on the form.
j. Shared Dwelling:
1) In the case of a veteran sharing a dwelling with another person who is not a family member as
defined in Operating Policy item IV(c),the rental amount will be prorated by the number of
people living in the dwelling.
2) In the case of a veteran sharing a dwelling with another person who is not a family member as
defined in Operating Policy item IV(c),the utility expenses will be prorated by the number of
people living in the dwelling.
3) In the case of a veteran sharing a dwelling with another person who is not a family member as
defined in Operating Policy item IV-c,the firewood/propane expenses will be prorated by the
number of people living in the dwelling.
k. When an applicant has requested assistance for past due utilities (electric,water or natural as) Il
(f)(2),and has gone through the screening process.The applicant must have a"Past Due"pink
slip(s)stating that service will be discontinued.
1. Some utilities companies,i.e.Shelton Utilities,do include garbage within the water bill,in this
situation where the bill is"combined",the whole bill is paid.
m. The VSO will call the utilities company to verify the current amount to be paid,and inform them
that the veteran has applied for assistance and that a letter of"Recommendation for Payment"
(Att.G) will be forthcoming.
n. When an applicant requests assistance for firewood or propane and has gone through the
screening process,the VSO will call a vendor to confirm prices and amount needed.The VSO will
inform the vendor,the veteran has applied for assistance and that a letter of"Recommendation for
Payment" (AttG) will be forthcoming,VII (j)(3)also applies.
o. The VSO will then fill out a"Purchase Order" (AttH) to be sent with"Assistance Fund Application"
(AFA) (Att.C)for approval from MCC.
p. When an applicant requests Miscellaneous Items or Other Items and has gone through the
screening process,the VSO will,to the best of their ability,determine the needs of the applicant
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Adopted 08/21/2018
q. The VSO will fill out the"Assistance Fund Application" (AFA) (Att.C),determine the amount,the
vendor,and have the applicant sign the application with a full understanding of the request.
r. Necessity Items check(s)are issued in fifty dollar increments.The applicant will be given an
itemized list of authorized items that may be purchased. (Att.A)
s. After all needed information and documentation is gathered from the applicant and outside
sources,the AFA is then completely filled out and the packet is complete.
t. It is the VSOs'responsibility to ensure all information in the packet is correct and verified.
u. When the completed packet is sent on to MCC,it will have a copy of"Recommendation for
Payment"as a cover sheet(Att.G)or"Assistance Fund Application"(Att.C).
v. The VSO reserves the right to refuse service to disorderly or abusive individuals.Service will be
refused to individuals under the influence of alcohol and/or drugs.Applicants who are disorderly
or abusive to Mason County employees or volunteers will be not be provided assistance and will be
asked to leave the building.
VIII. Processing of Packet Procedures
a. Once the packet is received at the MCC office,it is date stamped and reviewed to ensure all
information is correct and all supporting documentation is there.
b. Applications submitted to the MCC for processing and have been determined to meet the necessary
guidelines will have checks issued within three business days.
c. Applicants who pick up his/or her check(s),must have proper picture ID,and must sign for
check(s).Check(s)are sent out by mail the next business day following approval.
d. Necessity Item check(s) that are issued will be stamped with: "No Alcohol or Tobacco","No Cash
Back".
e. Some delays may result if a legal holiday falls within the time period or if there are insufficient
funds to release the check.
f. A weekly list of"Approval of Expenditures"is sent to the VSO's office from the MCC office.
g. A monthly list of"Approval of Expenditures"is sent to the MCC.
IX. Records, Files, Forms and Reports
a. It will be the responsibility of the VAB Chair,acting in concert with the VSO's to establish and
maintain a record of each applicant requesting and/or receiving assistance from the VAF.
b. The VSO will provide forms and reports of attendants,decisions,and record-keeping for clientele,
e.g.,forms for vendors,initial applications,and VAB decisions.
c. Each October,the VAB,acting in concert with the VSOs shall produce an annual report for the MCC,
containing the following information:
1) The number of requests for assistance received during the calendar year.
2) The number of requests for assistance for which assistance was given.
3) The number of requests for assistance for which assistance was not provided and a narrative
description of the reasons assistance were not provided.
4) The total dollar value of assistance provided on a monthly basis.
5) A narrative description of non-monetary assistance provided by the VAB.
6) Meeting minutes as an attachment.
7) A copy of appeals as an attachment.
d. If any section of these policies or procedures is determined to be in conflict with federal,state.or
county laws,ordinances or directives,then said section will be void and the aforementioned laws,
ordinances or directives shall prevail.
Page 7 of 8
Adopted 08/21/2018
X. Attachments (Att.)
A.VAF Necessity Itemized List
B.Income Guidelines for Mason County(HHS)
C.Assistance Fund Application(AFA)
D.Rental/Mortgage Verification
E.Veteran's Assistance Documents Checklist(S&S form)
F.Request Pertaining to Military Records(Standard Form 180)
G.Recommendation For Payment
H.Mason County Veterans Service Office-Purchase Order
Page 8 of 8
Adopted 08/21/2018
Veterans Assistance Fund (VAF) ATTACHMENT A
Necessity Items
FOOD ITEMS FOOD ITEMS
Baby Food Milk Substitutes-soy, rice or almond
Baby Formula Nuts
Breads&Tortillas Pasta
Canned Soups Peanut Butter
Cereals Potatoes
Cheese Rice
Condiments Seafood-fresh,frozen,canned&dried
Cottage Cheese Spices
Corn Meal Vegetables-fresh,frozen,canned&dried
Dairy&Dairy Substitutes Yogurt
Dried Peas& Beans NON-FOOD ITEMS
Eggs& Egg Substitutes Cleaning Products
Ensure(Nutritional Drink) Dental Products
Fish-Fresh,frozen,canned&dried Shaving Products
Flour-all types Deodorant
Fruit-fresh,frozen,canned &dried Diapers-Baby-Adult
Glucerna Drink(for diabetics) Dish&Bath Soap
Grains Toilet Paper
Juice, 100% Feminine Hygiene Items
Legumes&beans Laundry Detergent
Meat-fresh,frozen,canned&dried Paper Towels
Milk-fresh,canned& powdered Shampoo
ATTACHMENT B
2018
INCOME GUIDELINES FOR
MASON COUNTY
VETERANS ASSISTANCE FUND
(effective 1/13/2018)
HOUSEHOLD SIZE] 1000/ -
o_ 150%-11.1.--.-...-.-...
ANNUAL INCOME ANNUAL INCOME MONTHLY INCOME
........... .......
1 12,140 ---.1,518
2 16,460 24,690 ...............2,058
3 20,780 31,170 i 2,598
4 25,100 37,650 3,138
5 29,420 44,130 .-... 3,678
6 33,740 50,610 4,218
7 38,060 57,090 4,758
8 ----...42,380 63,570 .5,298
For each additional person add 4,320 61480540
.................I.-..-
*The federally-established overt y guide'll nes Is--s-u--e--d—!y the US Department of Health and Human Services
httl2://aspe.hhs.gov/goverty -------
I .--.-.............................
See VAB Operating Poli IV.(g
..........
Allowable income after taxes(p e r S H B 1189, New Sec!2, (3)(b))
0:\USER\CBCOMMON\EXCEL\2018 INCOME GUIDELINES.xlsx Page 1 1/1612018;2:26 PM
ATTACI-IMF,NT C
The Veterans Service Office
In Mason County, Washington
Second and Franklin Streets
Post Office Box 8, Shelton, WA 98584
360-426-4546
Assistance Fund Application
Date
Client Name
Address
Phone
(E-mail if available)_
Eligibility
Branch of Service _
Service Number SS#
Date of Entry
Date of Discharge
Type Discharge _
War Period or Campaign award for participation in armed conflict.
(See RCW 41.04.005)
NVWI 4/6/17_11/12/18_NVWI Russia 4/6/17—4/01/20—WWII 12/07/41-12/31/46
Korean 6-27-50—1/31/55 Vietnam 8/05/64—5/07/75 Persian Gulf 8/02/90--
Grenada _Lebanon_Panama(Op. "Just Cause")_Somalia (Op. "Restore Hope")
Haiti (Op. "Uphold Democracy")_Bosnia (Op."Joint Endeavor") Other
State Residency
County Residency
Page 1 of 4
ATTACHMENT C
Family
Spouse Name _
Address (if different):
Dependents other than spouse
Names, Ages, Addresses (if different)
EMPLOYMENT
Veteran No Yes Where
How Long
Salary Mo/Hr
Spouse No Yes Where
How Long
Salary Mo/Hr
CURRENT NEED:
Page 2 of 4
ATTACHMENT C
1
INCOME
Self, Spouse, Dependents - Previous 90 Days
Full or Part-Time Work Unemployment
Public Assistance Child Support
VA Comp/Disability Alimony
VA Pension/School State Disability
Social Security—Total Retirement
Veteran Property
Spouse Food Stamps
Dependents Other
Other Other
Total Household Income
NOTE: Verification of income is required!!
Expenses
Self, Spouse, Dependents - 12 month average
Rent/Lease/Mortgage Assessed Value
Landlord/Lien Holder
Address to be paid to
Electric Child Support
Gas/Fuel/Oil Wood VA Over-payment
Water SS Over-payment
Medicine Food
Doctor/Dentist Transport. (gas)
Health Ins.Prem. Car Insurance
Medicare Prem. Car Payment
Garbage Telephone
Property Taxes Cable/Satellite
Renter's/Home Ins. Internet
Maint. Fees Credit Cards
Comm. Club Fees Student Loans
Day Care Other
Total
Page 3 of 4
ATTACHMENT C
Signature of Veteran
Date
*NOTE: By signing this document, I swear that, to the best of my knowledge, the
information is true and correct. I further realize that if proven to be a deliberate
falsification, I will lose all rights to any future assistance.
Signature of Service Team Member
Approve Disapprove
Please pay the following vendors:
We,Mason County,Washington do hereby certify that the merchandise or services herein specified have
been received.
Staff review and processed by: Print Name
VAF Imprest Account Signer: Print Name
Check#
Amount: S
Payable To:
Check#
Amount: S
Payable To:
Check#
Amount: S
Payable To:
Check#
Amount: S
Payable To:
Page 4 of 4
ATTACHMENT D
VETERAN'S ASSISTANCE RENTAL/MORTGAGE VERIFICATION
Date
Veteran's Name Phone#
Address of Property
Mailing Address of Leasee
Name of Landlord/Lien Holder dllMaA,1,#;
Mailing Address of
Landlord/Lien Holder
(PLEASE PRINT CLEARLY)
Phone Number of Landlord/Lien Holder(Area code and number):
Amount of Rent/Payment Weekly/Semi-monthly/ Monthly
Does this amount include any utilities?
Which ones?
Amount in arrears as of the date of this form
I,the undersigned,swear or affirm that the answers to the questions hereon are true and correct and I
understand should any answer be proven false upon investigation,I may forfeit my right to assistance under
the Veteran's Relief Act of the State of Washington and incur such other penalties as may be prescribed by
law. I further agree to release any information regarding my case that may be in the possession of other
relief agencies.By making application to the Relief Fund,I permit the investigation officer to make discreet
inquiries as may be necessary,
Signature of Landlord/Lien Holder
Printed name of Landlord/Lien Holder
Verification must be from the Owner/Mortgage holder of said property unless payment will NOT stop
eviction.
SUBSCRIBED AND SWORN to before me this day of , 20
Notary Name:
NOTARY PUBLIC IN AND FOR THE STATE OF WASHINGTON
Residing at
Commissioner Expires
ATTACHMENT E
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PPob£f7'•l�icoi�ae For Last Three Month's For entire Household
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.Pay,,Stubs Boh Statenie ts- Unemploymn t D:ocuwent!` Q(
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Past due Ment -M-ortgagjb P TDy G ty tlt y r s r i e '-
- Neral has Private=or,Gated Community's°Maintenance-fee
Propane Food vouchers _ Fire Wood Wool Pellets Btiu'i.al
For VA Claim/Pension
h ili=tag/Civilian Med cil-°Records Y/N. ; Mental Health Eval iation's Y/N
Names, ddrss;=l?!Yioner:s of boctor ;:Clinic;lostal .. Y/1�T . .
Budd Letters- YN .Doctois.Stiati3ixse is YN l efer�rai /1 T.
�.r:
I�yaiageCrt Yom: "DjlorceC :'._.:.Y/ T. Ylf°__:;> _
Car�ents•
•. :�.. - .ter` �KJ•• - •
ATTACHMENT E
S'&S VE
' ASSrST
VEr�ERAN'S NAME: NCE DOC
�CUNjE�I
DbREss ro !i S CE�'KLIST
ONTACr VETE v, --``�--
PRONE
MBER(S) T'O ('ONTACT
TER4N;
1
VSO's NAME:
' DATE;
Tlie following items are needed by the coup
ty veteran, Check off items you have. Write "N//All i rnot a Processt 1 cab he kation for the above named
DD214 or similar document verifyinll Vet was honorabl dischar
State residency proof for last twelve months. Y ged.
County residency proof for last three months, to VSO's satisfaction.
_ Income proof for last three months for entire household. Examples: Pay stubs
Bank deposits, If unemployed: Form "Q01" from WorkSource. '"
Proof of expenses
Proof of financial emergency:
_Food
Rent past due: Rental form, filled out and Notarized.
Uh_ 'lity bills) past due, if separate:
Water bill
Heat (Electrical, Propane, Firewood, te.)
Electricity
_Phone (If veteran needs it for medical reasons)
Garbage
Other
NOTES:
Attachment F
Standard Form 180(Rev.5/12) (Page 1) Authorized for local reproduction
Prescribed by NARA(36 CFR 1228.168(b)l Previous edition unusable OMB No.3095-0029 apires 01/3113015.
REQUEST PERTAINING TO MILITARY RECORDS
'Requests from veterans or deceased veteran's next-of-kin may be submitted online by using eVetRers at http://www.archives.gov/veterans/military-service-records/'
(Co ensure the bestoe ssible service,please thoroughly review the accomparrying instructions before 2EU2g out this orm. Please print clearly or t e.
SECTION I-INFORMATION NEEDED TO LOCATE RECORDS(Furnish as much aspossible.)
1. NAME USED DURING SERVICE(last,first,andmiddle) 2. SOCIAL SECURITY NO. 3. DATE OF BIRTH 4. PLACE OF BIRTH
5. SERVICE,PAST AND PRESENT (For an effective records search,it is important that all service be shown below.)
BRANCH OF SERVICE DATE ENTERED DATE RELEASED OFFICER ENLISTED SERVICE NUMBER
(If unknown,write"unknown")
A.AC17VE
CO.MYONENT
b.RESERVE
COMPONENT
C. NATIONAL
GUARD
6. IS THIS PERSON DECEASED? If"YES"enter the date of death. 7. IS(WAS)THIS PERSON RETIRED FROM MILITARY SERVICE?
❑ NO ❑ YES ❑ NO ❑ YES
SECTION II—INFORMATION AND/OR DOCUMENTS REQUESTED
1. CHECK THE ITEM(S)YOU ARE REQUESTING:
❑ DD Form 214 or equivalent.When was the DD Form(s)214 issued? YEAR(S):
If more than one period of service was performed,even in the same branch,there may be more than one DD214.
This form contains information normally needed to verify military service.A copy may be sent to the veteran,the deceased veteran's next of kin,or
other persons or organizations if authorized in Section 111,below.An UNDELETED DD214 is ordinarily required to determine eligibility for
benefits. Sensitive items,such as,the character of separation,authority for separation,reason for separation,reenlistment eligibility code,
separation(SPD/SPN)code,and dates df time lost are usually shown.
An undeleted copy will be sent unless you specify a deleted copy. Indicate here if you want a deleted copy of the DD Form 214.❑.
The following items are deleted: authority for separation,reason for separation,reenlistment eligibility code,separation(SPD/SPN)code,and for
separations after June 30, 1979,character of separation and dates of time lost.
❑ All Documents in Official Military Personnel File(OMPF)
❑ Medical Records(Includes Service Treatment Records,Health(outpatient)and dental records.) If hospitalized(inpatient),the facility name and
date for each admission must be provided:
❑ Other(Specify):
2. PURPOSE: (An explanation of the purpose of the request is strictly voluntary;however,such information may help to provide the best possible
response and may result in a faster reply. Information provided will in noway be used to make a decision to deny the request.) Check appropriate box:
❑ Benefits ❑ Employment ❑ VA Loan Programs ❑ Medical ❑ Genealogy ❑ Correction ❑ Personal
❑ Other,explain:
SECTION III-RETURN ADDRESS AND SIGNATURE
1. REQUESTER 1S: (Signature Required ink 3 below ofveteran,nest ofkin,legal guardian,outhorizedgovernment agent or"other"authorized representative. If
"other"authorized representative,provide copy ofouthorization letter.) No signature required for Archival records.
❑ Military service member or veteran identified in Section 1,above ❑ Legal guardian(Must submit copy of court appointment)
❑ Next of kin of deceased veteran: ❑ Other(specify)
(Relationship)
MUST HAVE PROOF OF DEATH-See item 2a on instruction sheet- 3. AUTHORIZATION SIGNATURE WHEN REQUIRED(See items 20 or 3a
on accompanying instructions.) I declare(or certify,verify,or state)under penalty
2. SEND INFORMATION/DOCUMENTS TO: of perjury under the laws of the United States of America that the information in
(Please print or type. See item 4 on accompanying instructions.) this Section 111 is true and correct No signature required for Archival records.
Name Signature Required-Do not print Date
Street Apt. Daytime phone Fax Number
Cin State Zip Code Email address
*This form is available az http://tivwtiv.archives.gov/reseorch/order/standard form-180.pdfon the National Archives and Records Administration(NARA)web site."
Veterans' Advisory Board Manual, December 2013 16
--- Attachment F
Standard Form 180(Rev.5/12)(Page 2) Authorized for local reproduction
Prescribed by NARA(36 CFR 1228.168(6)) Previous edition unusable OMB No.3095-0029 Expires 0 1131/2015
LOCATION OF MILITARY RECORDS
rhe various categories of military service records are described in the chart below.For each category there is a code number which indicates the address
at the bottom of the page to which this request should be sent Please refer to the Instruction and Information Sheet accompanying this form as needed.
ADDRESS CODE
Medical or
BRANCH CURRENT STATUS OF SERVICE MEMBERService
en°°nel Record Treatment
Record
Discharged,deceased,orretired before 5/1/1994 14 14
Discharged,deceased,or retired 5/1/1994—9/302004 14 11
AIR Discharged,deceased,or retired on or after 10/12004 1 1 I
FORCE Active(including National Guard on active duty in the Air Force),TDRL,or general officers retired with pay 1
Reserve,retired reserve in nonpay status,current National Guard officers not on active duty in the Air Force,or 2
National Guard released from active duty in the Air Force
Current National Guard enlisted not on active duty in the Air Force 13
Discharge,deceased,or retired before 1/1/1898 6
COAST Discharged,deceased,or retired 1/1/1898-3/31/1998 14 14
GUARD Discharged,deceased,or retired on or after 4/1/1998 14 11
Active,reserve,or TDRL 3
Discharged,deceased,or retired before 1/1/1905 6
Discharged,deceased,or retired 1/1/1905—4/30/1 n4 14 14
MARINE Discharged,deceased,or retired 5/1/1994—12/31/1998 14 11
CORPS Discharged,deceased,or retired on or after 1/1/1999 4 11
Individual Ready Reserve 5
Active,Selected Marine Corps Reserve,TDRL 4
Discharged,deceased,or retired before 11/1/]912(enlisted)or before 7/1/1917(officer) 6
Discharged,deceased,or retired I(71/1912—10/15/1992(enlisted)or 7/l/1917—10/15/1992(officer) 14
ARMY Discharged,deceased,or retired after fb/16/1992 14 11
Active enlisted,officers 7
Former National Guard/USAR personnel 14
Discharged,deceased,or retired before 1/1/1886(enlisted)or before 1/1/1903 officer 6
Discharged,deceased,or retired 1/1/1886—1/30/1994(enlisted)or 1/1/1903-1/30/1994(officer) 14 14
N'AVY Discharged,deceased,or retired 1/31/1994—12/31/1994 14 11
Discharged,deceased,or retired on or after 1/1/1995 10 11
Active,reserve,or TDRL 10
PHS Public Health Service - Commissioned Corps officers only 12
ADDRESS LIST OF CUSTODIANS(BY CODE NUMBERS SHOWN ABOVE)—Where to write/send this form
National Archives&Records Administration
Air Force e!Center Old Military and Civil Records(NWCTS-MilitaryAccords Man
) Department a Veterans Affairs
HQ AFPC/DPSIRDPSIRP agement Center
1 550 C Street West,Suite 19 6 Textual Services Division 11 P.O.Box 5020
Randolph AFB,TX 781504721 700 Pennsylvania Ave,N.W. SL Louis,MO 63115-5020
Washington,DC 20408-OMI
Air Reserve Personnel Center US Army Human Resources Command
: ARRC-PDR-V Division of Commissioned Corps Officer Support
Records Management Branch ATTN
(DPTARA) A7-IN: Records Officer
2 16420 E.Silver Creek Ave. 7 1600 Spearhead Division Ave.,Dept 420 12 1101 Wooton Parkway,Plaza lcvel,Suite 100
Fort Knox,KY 40122-5402
Bldg.390 MS 68 askhr"rmy@us.army.mil Rockville,MD 20852
Bucklev AFB.CO 80011 _
Commander, Personnel Service Center
(PSD-MR)MS7200
US Coast Guard 13 Reserved
3 8 Reserved
4200 Wilson Blvd.,Suite 1100
Arlington,VA 29598-7200
b ttp://uscg.m iUpsdadm
Headquarters U.S.Marine Corps National Personnel Records Center
:Manpower Nlanagement Support Branch 4] (MMSE-10) 9 Reserved (Military Personnel Records)
4 (MMSB-10) 9 Rid
2008 Elliot Road 1 Archives Dr.
Quantico,VA 22134-5030 14 SL Louis,MO 63138-1002
Marine Forces Reserve Navy Personnel Command(PERS-312E) eVetRecs!
$ 4400 Dauphine St 10 5720 Integrity Drive hrtp:tlwww.archiveLgoWveseransImU&ary-serWce-records/
New Orleans,LA 70146~5400 Millington,TN 38055.3120
17
Veterans'Advisory Board Manual.December 2013 --
-- Attachment F
INSTRUCTION AND INFORMATION SHEET FOR SF 180, REQUEST PERTAINING TO MILITARY RECORDS
L General Information. The Standard Form 180, Request Pertaining to Military Records (SF180) is used to request information from
military records.Certain identifying information is necessary to determine the location of an individual's record of military service. Please
try to answer each item on the SF 180. If you do not have and cannot obtain the information for an item, show "NA," meaning the
information is"not available." Include as much of the requested information as you can. Incomplete information may delay response time.
To determine where to mail this request see Page 2 of the SF180 for record locations and facility addresses.
Online requests may be submitted to the National Personnel Records Center(NPRC) by a veteran or deceased veteran's next of kin using
eVetRecs at http://www.archives.gov/veterans/military-service-records/.
2. Personnel Records/Military Human Resource Records/Official Military Personnel File (OMPF) and Medical Records/Service
Treatment Records (STR). Personnel records of military members who were discharged, retired, or died in service less than 62 years
ago and medical records are in the legal custody of the military service department and are administered in accordance with rules issued by
the Department of Defense and the Department of Homeland Security(DHS,Coast Guard). STR's of persons on active duty are generally
kept at the local servicing clinic, and usually are available from the Department of Veterans Affairs approximately 40 days after the last
day of active duty. (See item 3,Archival Records,if the military member was discharged,retired or died in service over 62 years ago.)
a. Release of information: Release of information is subject to restrictions imposed by the military services consistent with
Department of Defense regulations and the provisions of the Freedom of Information Act(FOIA)and the Privacy Act of 1974.The
service member (either past or present) or the member's legal guardian has access to almost any information contained in that
member's own record.An authorization signature,of the service member or the member's legal guardian,is needed in Section 111 of
the SF180. Others requesting information from military personnel records and/or STR's must have the release authorization in
Section 111 of the SF 180 signed by the member or legal guardian. If the appropriate signature cannot be obtained, only limited
types of information can be provided.If the former member is deceased,surviving next of kin may,under certain circumstances,be
entitled to greater access to a deceased veteran's records than a member of the general public.The next of kin may be any of the
following: anremarried surviving spouse, father, mother,son,daughter,sister,or brother.Requesters must provide proof of death,
such as a copy of a death certificate, newspaper article (obituary) or death notice, coroner's report of death; funeral
director's signed statement of death,or verdict of coroner's jury.
b. Fees for records: There is no charge for most services provided to service members or next of kin of deceased veterans. A
nominal fee is charged for certain types of service. In most instances service fees cannot be determined in advance. If your request
involves'a service fee,you will'be notified.
3. Archival Records. Personnel records of military members who were discharged,retired,or died in service 62 or more years ago have
been transferred to the legal custody of NARA and are referred to as"archival"records.
a. Release of Information: Archival records are open to the public. The Privacy Act of 1974 does not apply to archival records.
therefore. written authorization from the veteran or next of kin is not required. However, in order to protect the privacy of the
veteran,his/her family, and third parties named in the records, the personal privacy exemption of the Freedom of Information Act(5
U.S.C. 552(b)(6)) may still apply and preclude the release of some information.
b. Fees for Archival Records: Access to archival records is granted by offering copies of the records for a fee(44 U.S.C.21 16(c)).
You will be notified if there is a charge for photocopies of documents contained in the record you are requesting. For more
information see http://www.archives.gov/st-louis/archival-programs/military-personnel-archival/ompf-archival-requcsts.htm1.
4.Where reply may be sent.The reply may be sent to the service member or any other address designated by the service member or other
authorized requester.
5. Definitions and abbreviations. DISCHARGED -- the individual has no current military status; SERVICE TREATMENT RECORD
(STR)--The chronology of medical,mental health and dental care received by service members during the course of their military career
(does not include records of treatment while hospitalized);TDRL—Temporary Disability Retired List.
6. Service completed before World War I.National Archives Trust Fund(NATF) forms must be used to request these.records. Obtain
the forms by e-mail from inquire@_)nara.gov or write to the Code 6 address on page 2 of the SF 180.
PRIVACY ACT OF 1974 COMPLIANCE INFORMATION
The following information is provided in accordance with 5 U.S.C. 552a(e)(3)and applies to this form.Authority for collection of the information is 44
U.S.C.2907.3101;and 3103,and Public Law 104-134(April 26, 1996),as amended in title 31,section 7701.Disclosure of the information is voluntary.If
the requested information is not provided,it may delay servicing your inquiry because the facility servicing the service member's record may not have all of
the information needed to locate it.The purpose of the information on this fbnn is to assist the facility servicing the records(see the address list)in locating
the correct military service record(s)or information to answer your inquiry.This form is then retained as a record of disclosure.The form may also be
disclosed to Department of Defense components,the Department of Veterans Affairs,the Department of Homeland Security(DHS,U.S.Coast Guard);or
the National Archives and Records Administration when the original custodian of the military health and personnel records transfers all or part of those
records to that agency. If the service member was a member of the National Guard, the form may also be disclosed to the Adjutant General of the
appropriate state.District of Columbia,or Puerto Rico,where he or she served.
PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT
Public burden reporting for this collection of information is estimated to be five minutes per request, including time for reviewing instructions and
completing and reviewing the collection of information.Send comments regarding the burden estimate or any other aspect of the collection of information.
including suggestions for reducing this burden,to National Archives and Records Administration(NHP),8601 Adelphi Road,College Park,MD 20740-
6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.SEND COMPLETED FORMS AS INDICATED IN THE ADDRESS LIST ON
PAGE 2 OF THE SF 180.
Veterans'Advisory Board Manual.DPcPmhPr 701:t 18
Attachment G
Veterans Service Office
Mason County, Washington
206 West Franklin Street
Post Office Box #8, Shelton, WA 98548-0008
Office: 360-426-4546/ Fax: 360-427-4491
"Recommendation For Payment„
®ate:
To:
Regarding:
The Veterans' Assistance Fund Screening Committee has
recommended to the Mason County Commissioners that they
approve payment of$ to you against the unpaid
account of . This fund is available to
all county veterans who have been determined eligible.
Based on the Commissioners' schedule, you may expect to
receive your funds on or about
If this payment is for rental assistance, the Commissioners will
not begin their process until they have received the
"Rental/Mortgage Verification" form this veteran has provided
to you.
The Veteran, and Staff of this office, and the office of the County
Commissioners all appreciate your patience with this process.
Service Officer:
Veterans'Advisonf Board Manual,December 2013
Attachment H
Mason County PURCHASE ORDER
Veterans Service Office
210 W. Franklin Street
Shelton,WA 98584 PO #2013 -
Phone: (360) 427-4546 Date
Fax: (360) 427-4491 Ordered By
VENDOR Company Name: SHIP TO
Contact:
Street Address:
City, State, Zip: Customer ID
Phone:
QTY ITEM# DESCRIPTION UNIT PRICE LINE TOTAL
Payment Details SUBTOTAL
❑ Check
ElCredit Card SHIPPING&
HANDLING
❑Account#
SALES TAX
TOTAL
Notes/Remarks Approval
19
Veterans'Advisory Board Manual, December 2013 --