HomeMy WebLinkAbout2024-056 - Res. Amending Res. 2023-007 Veterans' Advisory Board Policy RESOLUTION NO. aAQA-051P
RESOLUTION AMENDING RESOLUTION NO.2023-007
VETERANS' ADVISORY BOARDNETERANS' ASSISTANCE
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;and,
WHEREAS,RCW 73.08.035 authorizes the establishment of a Veterans' Advisory Board and the
Mason County Commissioners adopted Resolution no. 58-13 establishing the Veterans' Advisory Board
(VAB); and,
WHEREAS, RCW 73.08.010 provides for relief of indigent and suffering veterans and their
families or the families of those deceased veterans and on September 11, 2024 at the Veterans' Advisory
Board meeting the Board made the recommendation changes in Attachment A; and,
NOW, THEREFORE, BE IT RESOLVED, by the Board of County Commissioners of Mason
County that the Veterans' Advisory Board Operating Policy and Guidelines is amended to include the
changes shown in Attachment A.
DATED this 81 day of October,2024.
BOARD OF COUNTY COMMISSIONERS
ATTEST: MASON COUNTY, HINGTON
r
McKenzie S ith,eflerk of the Board Randy eatherlin,Chai
APPRO ORM:
Kevin Shutty, ce-Chair
Tim Whitehead,Chief Deputy Prosecuting
Attorney Sharon Trask,Commissioner
MASON COUNTY
VETERANS' ADVISORY BOARD
OPERATING POLICY &
PROCEDURES
Amendments are effective October 8, 2024.
Mason County,Washington
Randy Neatherlin,Chair
Kevin Shutty,Vice-Chair
ATTEST:
Sharon Trask,Commissioner
McKenzie Smith,Clerk of the Board
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..................................................................................................................................5
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.........................................................................................................8
X.List of Attachments(Att.)........................................................................................................................8
Page 2 of 8
Adopted September 2024
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. The veteran has to
have served as a member in any branch of the armed forces of the United States,including the national
guard and armed forces reserves,and fulfilled their initial military service obligation or as a member of
the armed forces reserves,national guard,or coast guard, and have been called into federal service by a
presidential select reserve call up for at least one hundred and eighty(180) cumulative days. Accepted
documents include the following: DD-214 showing Honorable,General Under Honorable or Other
Than Honorable(OTH)Discharge;DD215 Correction to Military Record DD-214;Honorable or
General Under Honorable Discharge Certificate;Reserve Discharges&Certificates;National Guard
Discharge NGB22,DD256, Certificates, and United States Department of Veteran Affairs Health ID
Card with acceptable secondary proof of income-to prove honorable discharge status.
d. These policies and procedures are subject to review annually by the Veteran's Advisory Board(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) The Mason County Board of County Commissioners(BOCC)has final approval of all revisions.
e. The VAB will meet the second Wednesday of each month at 8:45.a.m. at Memorial Hall located at 210
W Franklin Street 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 BOCC,use of the fund is governed by same RCW.
b. Approval of the one thousand eight hundred($1,800)dollars for assistance shall be granted only for
the following:
1) Rent or mortgage
i. First,last, deposit,and/or move in/move out costs
2) Utilities:
i. Electric
ii. Water
iii. Natural Gas
iv. Wastewater(sewer)
3.)Miscellaneous items:
i. Necessity Items(refer to list—Attachment A)
a. Single two hundred dollars($200.00)
b. Married three hundred dollars($300.00)
c. Plus an additional one hundred dollars ($100.00)per dependent
ii. Firewood or propane
iii. Clothing
Page 3 of 8
Adopted September 2024
4) Other Items
i. Obtain State identification card(one time only)
c. Exclusions will include,but are not limited to alcohol,tobacco, and lottery tickets.
d. Purchases in excess of the amount written on the check are the responsibility of the applicant.
e. No cash back will be given to the applicant if purchases are less than the amount written on the check.
f. All requests for assistance will be approved by the Veterans Service Officer(VSO),with final
approval by the BOCC.
g. If it is determined an applicant needs 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 two thousand($2,000.00)dollar lifetime limit per applicant. A Veteran does
not need to be defined as indigent to be eligible for catastrophic funds.
h. 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.
i. The VAF is not intended to provide continuing assistance on a routine basis.
j. The VAF shall not duplicate other available assistance for the purposes as noted in II(b).
III. Policy Establishing Board
a. RCW 73.08.035 states each county must establish a Veteran's Advisory Board,the Board shall advise
the BOCC 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, 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 BOCC reserves the right to disallow VAB appointee for cause.
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Adopted September 2024
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)found at hUs:Haspe.hhs.gov/pove!V-
guidelines
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 Mason County for at least ninety(90)days.
e. Applicant and anyone over the age of 18 in the household must present proof of residency and income.
Income verification must be from within the previous twelve(12)months. If no income, an affidavit
must be signed by both the veteran and household member(s)(Attachment B).
f. An applicant may use hotel/motel receipts as proof of residence,provided that:
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 after taxes and deductions for
medical insurance premium,including Medicare, of the veteran and all members of the household
must be at or below 150%of the poverty guidelines established by the HHS.
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 eight hundred($1,800)dollars.
b. The burial assistance is in addition to prior one thousand eight hundred($1,800.00)dollars limitation
as outlined in II-b.
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.
d. Applicants must provide either a death certificate or working death certificate in addition to the invoice
from the funeral home.
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.
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Adopted September 2024
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.
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 eligibility,an
"Assistance Fund Application(AFA)(Attachment C)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 the
"Veterans'Assistance Fund Documents Checklist" (Attachment E)to help them gather the needed
information.
d. If an applicant cannot show proof of service, a"Standard Form 180" (Attachment 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, 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 0)will apply.
h. When an applicant has requested assistance for rent or mortgage payment, II. (b)(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" (Attachment G)will be
forthcoming.
i. The applicant will then be given a form"Rental/Mortgage Verification" (Attachment 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.
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Adopted September 2024
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 utilities(electric,water,or natural gas)II(b)(2)and
has gone through the screening process,a copy of the utility bill must be provided for payment.If the
applicant has a past due amount and is at risk of shut off,the utility company will be contacted. When
an applicant is on a utility prepay account,the utility company must provide the daily rate applicable
to the prepay account. This daily rate must be attached to the applicant's AFA. The provided daily
rate will be multiplied by thirty(30)days to determine the total needed assistance amount.
1. Some utilities companies,i.e., City of Shelton utilities,include garbage within the water bill, in this
situation where the bill is"combined",the whole bill is paid.
in. 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" (Attachment
G)will be forthcoming.
n. When the 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 that the veteran has applied for assistance and that a letter of"Recommendation for Payment"
(Attachment G)will be forthcoming,VII(J)(3)also applies.
o. The VSO will then fill out a"Purchase Order" (Attachment H)to be sent with"Assistance Fund
Application" (AFA)(Attachment C)for approval. An invoice must be provided in order for payment
to be remitted.
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.
q. The VSO will fill out the"Assistance Fund Application" (AFA)(Attachment C),determine the
amount,the vendor,and have the applicant sign the application with a full understanding of the
request.
r. Necessity Item check(s)are issued various increments for a maximum of four(4)checks.New
applicants will be given an itemized list of authorized items that may be purchased(Attachment A).
s. After all needed information and documentation is gathered from the applicant and outside sources,the
AFA is then 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(Attachment G)or"Assistance Fund Application" (Attachment Q.
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 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 BOCC office, it is date stamped and reviewed to ensure all
information is correct and supporting documentation is provided.
b. Applications submitted to the BOCC for processing that have been determined to meet the necessary
guidelines will have checks issued within three business days.
c. Applicants who pick up their 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)are printed with: "No Alcohol or Tobacco", "No Cash Back".
Page 7 of 8
Adopted September 2024
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 BOCC office.
g. A monthly list of"Approval of Expenditures"is sent to the BOCC.
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
BOCC,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 4 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.
X. Attachments (Aft.)
A. VAF Necessity Itemized List
B.Affidavit of Income
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 September 2024
Attachment A
Veterans Assistance Fund
Necessity Items
Food Items Food Items
Baby Food Milk Substitutes—Soy,Rice,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 Substitutions Yogurt
Dried Peas &Beans
Eggs&Egg Substitutions Non-Food Items
Ensure(Nutritional Drink) Cleaning Products
Fish—Fresh,Frozen, Canned,Dried Dental Products
Flour—All Types Shaving Products
Fruit—Fresh,Frozen, Canned,Dried Deodorant
Glucerna Drink(for Diabetics) Diapers—Baby,Adult
Grains Dish&Bath Soap
Juice— 100% Toilet Paper
Legumes &Beans Feminine Hygiene Products
Meat—Fresh,Frozen, Canned,Dried Laundry Detergent
Milk—Fresh, Canned,Powdered Paper Towels
Shampoo
Attachment B
Affidavit of Income
Complete When No Income Declared
VETERAN:
I, , swear or affirm that I currently do not have any income of
any kind.
I do not have any current income because:
SPOUSE or DOMESTIC PARTNER:
swear or affirm that I currently do not have any income of
any kind.
I do not have any current income because:
DEPENDENT or HOUSEHOLD MEMBER:
swear or affirm that I currently do not have any income of
any kind.
I do not have any current income because:
I solemnly affirm under the penalties of perjury that the information provided in this Affidavit of
Income is true, correct, and complete to the best of my ability, belief, and knowledge. I further
realize that if proven to be a deliberate falsification, I will lose all rights to any future assistance.
Date Veteran Signature
Date Spouse or Domestic Partner Signature
Date Dependent or Household Signature
Veterans' Service Office
of Mason County
210 W Franklin Street
Shelton,WA 98584
Phone: (360)426-4546
Fax: (360)427-4491
Assistance Fund Application
❑ Belfair ❑ Shelton
Date: ❑ Mail to Client
❑ Client pick-up
Client Name:
Address:
Phone:
Email:
Eli ibili
Branch of Service:
Date of Entry:
Date of Discharge:
Type of Discharge: ❑ Honorable ❑ Other Than Honorable ❑ Dishonorable
War Period or Campaign Award for Participation in Armed Conflict—See RCW 41.04.005
❑ WWI (4/6/1917— 11/12/1918) ❑ WWI Russia(4/6/1917—4/1/1920)
❑ WWII (12/7/1941 — 12/31/1946) ❑ Korean (6/27/1950— 1/31/1955)
❑ Vietnam(8/5/1964—5/7/1975) ❑ Persian Gulf(8/2/1990— 1/17/1991)
❑ Grenada ❑ Panama(Op. "Just Cause") ❑ Somalia(Op. "Restore Hope")
❑ Haiti (Op. "Uphold Democracy") ❑ Bosnia(Op. "Joint Endeavor") ❑ Other = ,
State of Residency:
County of Residency:
Household
Spouse or Domestic Partner Name:
Address (if Different):
Dependents/Household Members(Include Names,Ages, and Addresses if Different)
Employment
Veteran- ❑ No ❑ Yes Where:
How Long:
Salary:
Spouse or Domestic Partner- ❑ No ❑ Yes Where:
How Long:
Salary: =
Dependent/Household Member- ❑ No ❑ Yes Where:
How Long:
Salary:
Income
Please note: verification of income is required.
Veteran
Full or Part-Time: Unemployment:
Public Assistance: Child Support:
VA Comp/Disability: Alimony:
VA Pension/School: State Disability:
Social Security: Property:
Retirement: Food Stamps:
Other: Total:
Spouse or Domestic Partner
Full or Part-Time: Unemployment:
Public Assistance: Child Support:
VA Comp/Disability: Alimony:
VA Pension/School: State Disability:
Social Security: Property:
Retirement: Food Stamps:
Other: Total:
Dependent/Household Member ,
Full or Part-Time: Unemployment:
Public Assistance: Child Support:
VA Comp/Disability: Alimony:
VA Pension/School: State Disability:
Social Security: Property:
Retirement: Food Stamps:
Other: Total:
Total Household Income:
2
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.
❑ I verify that I have been a resident of Mason County,Washington for at least 90 days.
Signature of Veteran: Date:
Signature of Service Team Member:
❑ Approve ❑ Disapprove
Please pay for the following assistance:
We,Mason County,Washington do hereby certify that the services herein specified have been received.
Staff Reviewed By: Date:
Staff Processed By: Date:
Veterans'Assistance Fund Account Signer: Date:
Check no. Check no.
Amount$ Amount$
Payable To Payable To
Check no. Check no.
Amount$ Amount$
Payable To Payable To
3
Attachment.D
Veterans Service Office
Mason County, Washington
206 W Franklin Street
P.O.Box 8
Shelton, WA 98584
Office: (360)426-4546 1 Fax: (360) 427-4491
Veterans' Assistance Fund
Rental/Mortgage Verification
Date:
Veteran's Name: Phone Number:
Address of Property: Parcel No:
Mailing Address of Lease:
Name of Landlord/Lienholder:
Phone Number of Landlord/Lienholder:
Amount of Rent/Payment: Weekly Semi-Monthly Monthly
Does this amount include any utilities?
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 it 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 inquires as may be necessary.
Signature of Landlord/Lienholder:
Verification must be from owner/mortgage holder only. This form must be notarized by an official
notary public. All payments will be mailed directly to the owner/mortgage holder of saidproperty,
unless payment will not stop eviction.
SUBSCRIBED AND SWORN before me on this day of ,20
NOTARY PUBLIC IN AND FOR THE STATE OF WASHINGTON
Residing at
Commission expires
Attachment E
Veterans Service Office
Mason County, Washington
206 W Franklin Street
P.O. Box 8
Shelton, WA 98584
Office: (360) 426-4546 1 Fax: (360)427-4491
Veteran's Assistance Fund
Documents Checklist
Veteran's Name:
Contact Address:
Contact Phone Number:
Veteran Service Officer Name: Date:
The following items are needed by the County to process the application for the above-named
veteran. Check off items you have,write "N/A" is not applicable.
DD214 or similar document verifying veteran was honorably discharged
State residency proof for last twelve (12)months
County residency proof for last three (3)months to VSO's satisfaction
Income proof for last three (3)months for entire household, ex:paystubs,bank deposits
If unemployed,Form QO1 from WorkSource
Proof of expenses
Proof of Financial Emergency
Food
Past due rent(Rental/Mortgage Verification form filled out and notarized)
Utilities Past Due (if separate)
Water bill
Heat(electrical,natural gas,propane, firewood, etc.)
Electricity
Phone (if needed for medical reasons)
Garbage
Other:
Notes:
INSTRUCTION AND INFORMATION SHEET FOR SF 180,REQUEST PERTAINING TO MILITARY RECORDS
1. 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). STRs of persons on active duty are generally kept at the local servicing clinic. After the last _
day of active duty,STRs should be requested from the appropriate address on page 2 of the SF 180. (See item 3,Archival Records,if the military member
was discharged,retired or died in service more than 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,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.The authorization signature of the service
member or the member's legal guardian is needed in Section III of the S17180. Others requesting information from military personnel records and/or
STRs must have the release authorization in Section III 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, the surviving next-bf-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: unremarried 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
receive an invoice with your records.
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. In order to protect the privacy of the veteran,his/her family,and third parties named irt.
the records,the personal privacy exemption of the Freedom of Information Act(5 U.S.C.552(b)(6))may still apply and may preclude the release
of some information.
b. Fees for Archival Records: Access to archival records are granted by offering copies of the records for a fee(44 U.S.C.2116(c)).If a fee applies.
to the photocopies of documents in the requested record,you will receive an invoice. Photocopies will be sent after payment is made. For more_
information see http://www.archives.gov/st-louis/archival-programs/military-personnel-archival/ompf-archival-requests.html.
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. If the designated address is NOT registered to the addressee by the U.S.Postal Service(USPS),provide BOTH the addressee's name AND"in
care of(c/o)the name of the person to whom the address is registered on the NAME line in Section III,item 3,on page 1 of the SF 180. The COMPLETE
address must be provided,INCLUDING any apartment/suite/unit/lot/space/etc.number. :
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.2907,3 10 1,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 form 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(ISSD),8601 Adelphi Road,College Park,MD 20740-
6001.DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS TO THE APPROPRIATE ADDRESS LISTED ON
PAGE 2 OF THE SF 180.
Standard Form 180(Rev.11/2015) (Page 1) Authorized for local reproduction
Prescribed by NARA(36 CFR 1233.18(d)) Previous edition unusable OMB No.3095-0029 Expires 04/30/2018
REQUEST PERTAINING TO MILITARY RECORDS
Requests from veterans or deceased veteran's next-of-kin may be submitted online by using eVetRecs at http://www.archives.gov/veterans/military-service-records/
To ensure the best possible service,please thoroughly review the accompanying instructions before filling out this form. PLEASE PRINT LEGIBLY OR TYPE BELOW.
x ._ SQL L£ tR1TrTtC?Nl�Cll��DfTO) UCTE.: CC7�RllS£(FtrmisTt,itsriiuch znformiutton:apossifit)�
1. NAME USED DURING SERVICE(last,first,full middle) 2. SOCIAL SECURITY# 13. DATE OF BIRTH 14. 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 DATE ENLISTED SERVICE NUMBER
OFFICER
ENTERED RELEASED (If unknown,write"unknown")
a. ACTIVE — ❑ ❑
b. RESERVE — ❑ ❑
c. STATE ❑ El
—
GUARD
6. IS THIS PERSON DECEASED? ❑ NO ❑ YES-MUST provide Date of Death if veteran is deceased:
7. DID THIS PERSON RETIRE FROM MILITARY SERVICE? ❑ NO ❑ YES
9'= N 3R1Y W416N A KD/OR;DQCU ENmS`ROQUESITU, r;.
1. CHECK THE ITEM(S)YOU ARE REQUESTING:
❑ DD Form 214 or equivalent. Year(s)in which form(s)issued to veteran:
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 III,below. An UNDELETED DD214 is ordinarily required to determine eligibility for benefits. If you
request a DELETED copy,the following items will be blacked out: 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.
An UNDELETED copy will be sent UNLESS YOUSPECIFYA DELETED COPY by checking this box. ❑I want a DELETED copy.
❑ Medical Records Includes Service Treatment Records,Health(outpatient)and Dental Records. IF HOSPITALIZED(inpatient)the FACILITY NAME and
DATE(month and year)for EACH admission MUST be provided.•
❑ Other(Specify):
2. PURPOSE: (Providing information about the purpose of the request is strictly voluntary;however,it may help to provide the best possible response and may
result in a faster reply. Information provided will in no way be used to make a decision to deny the request.)
❑ Benefits(explain) ❑ Employment ❑ VA Loan Programs ❑ Medical ❑ Genealogy ❑ Correction ❑ Personal ❑ Other(explain)
Explain here:
M �
F ' SEC [Oi`T IBC,KTCIRI�I Dl?RESD:.SGI�[ TTRE
1. REQUESTER NAME:
2.0 I am the MILITARY SERVICE MEMBER OR VETERAN identified in Section I am the VETERAN'S LEGAL GUARDIAN(MUST submit copy of Court
I,above. Appointment)or AUTHORIZED REPRESENTATIVE(MUST submit copy of
I am the DECEASED VETERAN'S NEXT-OF-KIN(MUST submit Proof of Authorization Letter or Power of Attorney)
Death. See item 2a on instruction sheet.) OTHER
(Relationship to deceased veteran) (Speck type of Other)
3. SEND INFORMATION/DOCUMENTS TO: 4. AUTHORIZATION SIGNATURE:I declare(or certify,verify,or
(Please print or type. See item 4 on accompanying instructions.) state)under penalty of perjury under the laws of the United States of
America that the information in this Section IH is true and correct and
that I authorize the release of the requested information.(See items 2a or
Name 3a on accompanying instruction sheet. Without the Authorization Signature
of the veteran,next-of-kin of deceased veteran,veteran's legal guardian,
authorized government agent,or other authorized representative,only
Street Apt. limited information can be released unless the request is archival No
signature is required if the request iffor archival records.)
City State Zip Cade
*This form is available at http✓lwww.archives govlveteransln ilitary-service- Signature Required-Do not print Date
records/standard form-180.himl on the National Archives and
Records Administration(NARA)web site.* Daytime phone Fax Number
Email address
Standard Form 180(Rev.11/2015)(Page 2) Authorized for local reproduction
Prescribed by NARA(36 CFR 1233.18(d)) Previous edition unusable OMB No.3095-0029 Expires 04/302018
The 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.
BRANCH CURRENT STATUS OF SERVICE MEMBER Personnel Medical or Service
Record Treatment Record
Discharged,deceased,or retired before 5/1/1994 14 14
Discharged,deceased,or retired 5/1/1994—9/302004 14 11
Discharged,deceased,or retired 10/1/2004—12/312013 1 11
AIR Discharged,deceased,or retired on or after 1/12014 1 13
FORCE Active(including National Guard on active duty in the Air Force),TDRL,or general officers retired with pay 1
Reserve,MR,Retired Reserve in non-pay status,current National Guard officers not on active duty in the Air Force,or National Guard 2
released from active duty in the Air Force
Current National Guard enlisted not on active duty in the Air Force 2 13
Discharge,deceased,or retired before 1/1/1898 6
Discharged,deceased,or retired 1/1/1898—3/31/1998 14 14
COAST Discharged,deceased,or retired 4/1/1998—9/302006 14 11
GUARD Discharged,deceased,or retired 10/1/2006—9/302013 3 11
Discharged,deceased,or retired on or after 10/12013 3 14
Active,Reserve,Individual Ready Reserve or TDRL 3
Discharged,deceased,or retired before l/1/1895 6
Discharged,deceased,or retired 1/l/1905—4/30/1994 14 14
Discharged,deceased,or retired 5/1/1994—12/31/1998 14 11
MARINE Discharged,deceased,or retired 1/1/1999-12/312013 4 11
CORPS
Discharged,deceased,or retired on or after 1/12014 4 8
Individual Ready Reserve 5
Active,Selected Marine Corps Reserve,TDRL 4 4,o
Discharged,deceased,or retired before 11/l/1912(enlisted)or before 7/1/1917(officer) 6
Discharged,deceased,or retired 11/l/1912—10/15/1992(enlisted)or 7/1/1917—10/15/1992(officer) 14
Discharged,deceased,or retired 10/16/1992—9/302002 14 11
ARMY Discharged,deceased,or retired(including TDRL)10/12002—12/31/2013 7 11
Discharged,deceased,or retired(including TDRL)on or after I/l2014 7 9'
Current Soldier(Active,Reserve(including Individual Ready Reserve)or National Guard) 7
Discharged,deceased,or retired before 1/l/1886(enlisted)or before 1/1/1903(officer) 6
Discharged,deceased,or retired 1/l/1886—1/30/1994(enlisted)or 1/1/1903—1/30/1994(officer) 14 14
Discharged,deceased,or retired 1/31/1994—12/31/1994 14 11
NAVY Discharged,deceased,or retired 1/1/1995—12/312013 10 11
Discharged,deceased,or retired on or after I/12014 10 8
Active,Reserve,or TDRL 10
PHS Public Health Service- Commissioned Corps officers only 12
ADDRESS LIST OF CUSTODIANS and SELF-SERVICE WEBSITES(BY CODE NUMBERS SHOWN ABOVE)—Where to write/send this form
Air Force Personnel Center National Archives&Records Administration Department of Veterans Affairs
HQ AFPC/DPSIRP Research Services(RDT1R) Records Management Center
1 550 C Street West,Suite 19 6 700 Pennsylvania Avenue NW 11 ATTN: Release of Information
Randolph AFB,TX 78150-4721 Washington,DC 20408-0001 P.O.Box 5020
St.Louis,MO 63115-5020
Air Reserve Personnel Center US Army Human Resources Command's web page:
Records Management Branch(DPTSC) htips://www.hrc.army.miLTAGD/Accessine'oZOor%ZO ATTDivision of Commissioned Corps Officer Support
2 18420 E.Silver Creek Avenue 7 ReauestineZo20YourVo20OFicia!%20Mifitarv%20Pers 1101 Records Officer
Building 390 MS 68 onnel%ZOFile%20Documents 12 1101 Wle,M Parkway,Playa Level,Suite 100
Buckley AFB,CO 80011 or 1-888-ARAlYHRC(1-888-276-9472) Rockville,MD 20852
Commander, Personnel Service Center AF STR Processing Center
(BOPS C-MR)MS7200 Navy Medicine Records Activity(NMRA) ATTN: Release of Information
US Coast Guard BUMED Detachment St Louis 13 3370 Nacogdoches Road,Suite 116
3 2703 Martin Luther King Jr Ave SE g 4300 Goodfellow Boulevard,Building 103 San Antonio,TX 78217
Washington,DC 20593-7200 St Louis,MO 63120
MR CustomerService(aluscr.mil National Personnel Records Center
(Military Personnel Records)
Headquarters U.S.Marine Corps 1 Archives Drive
Manpower Management Records&Performance AMEDD Record Processing Center 14 St Louis,MO 63138-1002
4 (MMRP-10) 9 3370 Nacogdoches Road,Suite 116
2008 Elliot Road San Antonio,TX 78217 eVetRecs:
Quantico,VA 22134-5030 htta://www.archives.eov/veterans/military-service-records/
Marine Forces Reserve Navy Personnel Command(PEAS-313)
5 2000 Opelousas Avenue 10 5720 Integrity Drive
New Orleans,LA 70146-5400 Millington,TN 38055-3120
Attachment G
Veterans Service Office
Mason County, Washington
206 W Franklin Street
P.O. Box 8
Shelton, WA 98584
Office: (360) 426-4546 1 Fax: (360) 427-4491
"Recommendation for Payment"
Date:
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
Commissioner's 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 that 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:
Attachment H
sA
ason Count M PURCIaSE (?RDER d$
y
Veterans Service Afficce.
210 W.Franklin Street
Shelton,WA 98584 PO#
Phone:(360)4274546 Date:
Fax:(360)4274491 Ordered By:
VENDOR Company Name: SHIP TO
Customer ID:
',3T1 ITEM# DESCRIPTION;; UPITT PI2iCE 5.
LINE TOTi1L
Payment Details SUBTOTAL
Check
SHIPPING&
Credit Card HANDLING
Account# SALES TAX
TOTAL
Notes/Remarks Approval
Signature Date.
j
r