Veterans Service Emergency Relief Gift Card Request

Applicant Namerequired

First Name

Middle (optional)

Last Name

Email Addressrequired

Phone Numberrequired

Streetrequired

Apt/Unit

Cityrequired

Staterequired

Zip Coderequired

Applicant's Date of Birthrequired

Must contain a date in MM/DD/YYYY format

Are you the veteran?required

Veteran's First and Last Namerequired

Veteran's Date of Birth

Must contain a date in MM/DD/YYYY format

Do you live with the veteran?

Circumstances on why you do not live with the Veteranrequired

Please explain why you are requesting assistance?required

Gift Card Requested requiredPlease select up to 1 choice

Grocery Card

Gas

Food (gift card for local resturant)

Please select up to 1 choice

If first gift card requested is unavailable, what would be your second choice?requiredPlease select up to 1 choice

Grocery Card

Gas

Food (gift card for local resturant)

Please select up to 1 choice

Please select up to 6 choices

Type of ServicerequiredPlease select up to 2 choices

Active Duty (for other than training)

Traditional National Guard/Reserve

Please select up to 2 choices

Type of Dischargerequired

Required Documentation

Without the documentation, the application will be denied. If unable to add, please reach out to Dodge County Veterans Services directly after submission.

Proof of Dodge County Residency

Attach up to 5 files with a maximum size of 10MB

No file chosen

Proof of Service

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.

Statement of Truth

I confirm that the identifying information in this for is accurate and has been represented correctly.

Terms of Applicationrequired

I certify that the above information is true and correct to the best of my knowledge and my application for assistance is because of a need for help at this time. I understand any misrepresentation or falsification of any information will make me ineligible for assistance. I understand by not completing all sections in the application or failing to provide all requested documents will cause my application to be denied. By signing this form, I am giving my permission for the County Veteran Service Officer to obtain personal information from other agencies to include but not limited to Dodge County Human Services and Health, Center for Veterans Issues, VORP.

Dodge County Veterans Service Commission Fund Guidelinesrequired

There is no per year or lifetime limit for VSC funds. It is to be handled on a case by case basis. Complete guidelines can be found on the Dodge County Veterans Services Website.

Type of Service

To receive a grant from the Veterans Service Commission the veteran had to have served on “active duty” at least one day or completed full-service obligation for the National Guard/Reserves. “Active duty for training” does not qualify. Proof of completion of reserve obligation is required (1) To receive a grant from the Veterans Service Commission the veteran had to have had an “honorable” discharge. An “Under honorable conditions” does not qualify. However, the honorable discharge does not have to have been the last discharge if there were more than one period of service. (2)

Residency Requirement

To receive a grant from the Veterans Service Commission the veteran must provide proof of Dodge County residency (rental agreement, utility bill, telephone bill etc). There is no minimum time of residency required.

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Veterans Service Emergency Relief Gift Card Request

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