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Dodge County Emergency Relief Request

Required

Applicant Namerequired
First Name
Middle (optional)
Last Name
Must contain a date in MM/DD/YYYY format
Must contain a date in MM/DD/YYYY format
Must provide full name and account number of who you would like the money to be sent to.
Must provide address of where to send the assistance to
Must contain a date in MM/DD/YYYY format
Must provide Company Name, Account Number, Amount, Where to send the money and due date
Military Service
Military ServicerequiredPlease select up to 6 choices
Please select up to 6 choices
Type of ServicerequiredPlease select up to 2 choices
Please select up to 2 choices
Family Information
Employment Information
Monthly Bills and Living Expenses
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Please note if you are in the arrears for any support
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Do not leave any blank. If you do not have this bill, please put 0 or N/A
Income & Assets Information
Do you have any of the following?requiredPlease select up to 5 choices
Please select up to 5 choices
If applicant has these, it does not mean they are not eligible for assistance.
If applicant has these, it does not mean they are not eligible for assistance.
Does your spouse have any of the following?requiredIf they are combined with yours, do not duplicate any that have previously been submitted.
If they are combined with yours, do not duplicate any that have previously been submitted.
Please list the Make/Model/Year, Amount Owed and Value for each additional vehicle
Do you or your spouse own any of the followingrequiredPlease select up to 4 choices
Please select up to 4 choices
Type, Amount Owed, Value
Assistance
Have you applied for any of the following?Please select up to 8 choices
Please select up to 8 choices
Have you received any assistance from any Veterans Service Commission, American Legion, VFW or other VSO within the past 12 months?
Example: Rental Assistance, $450 in June 2025 from the Dodge County Veterans Services
Required Documentation
 
If you do not wish to upload documents here, please email or fax them. 920-386-3271 or krhyner@co.dodge.wi.us 
 
Without the documentation, the application will be denied. 
Attach up to 5 files with a maximum size of 10MB
No file chosen
Attach up to 1 file with a maximum size of 10MB
No file chosen
Attach up to 5 files with a maximum size of 10MB
No file chosen
Attach up to 3 files with a maximum size of 10MB
No file chosen
If DCVSO already as the DD214, you do not need to provide it again.
Terms of Applicationrequired
Limits of the Veterans Service Commissionrequired