APPENDIX - A Documents Needed for Verification (Only one document is needed for each category unless otherwise noted.) a) Proof of service i) DD-214 or equivalent ii) VA Statement of Service (SOS) iii) If discharged prior to 1950 a Certificate of Discharge iv) Photo ID Veterans Affairs Medical Card. b) Verification of Residency i) Utility Bill ii) Washington State Drivers iii) DSHS verification printout iv) Social Security documentation v) Military disability documentation vi) W-2 form for prior year vii) Homeless veterans would have to have mail delivered to city or post office within county. viii) State ID card ix) Rental agreement c) Picture ID i) Washington State Driver’s License ii) State I.D. card (Department of Corrections, College, iii) Military ID card if in National Guard iv) VA medical ID v) Any ID not list has to have SSN# that matches or verifying information unique to that veteran (signature, service number, etc.) d) Proof of Marriage i) Marriage Certificate ii) Tax Return with married filing jointly iii) Military Spouses ID card iv) DSHS verification form with both names on it v) Death certificate e) Verification of Dependent i) Birth Certificate ii) Dependent Military ID iii) Adoption paperwork iv) Verification from school district (This is for grandparents or nonparent custodial who is main supply of benefits for children but cannot acquire other documents.) v) DSHS(Department of Social and Health Services) Income verification vi) SSDI (Social Security Disability Income) vii) Death Certificate f) Death Verification i) Death Certificate h) Income Verification Documents i) Bank statement for the last three months ii) If no bank account DSHS verification of income printout. g) ( for over 18 years of age who are considered disabled dependents) i) DSHS Income verification ii) SSDI income verification i) Income Verification continued (all that apply of the following documents minimum of one if no bank account) i) W-2 withholding statement from all employers for the previous year ii) Pay stubs from all employers for the previous year iii) An income tax return from most recently filed calendar year iv) Forms approving or denying eligibility for Medicaid and/or state funded assistance v) Forms approving or denying unemployment compensation vi) Written statement from all employers for the previous year or welfare agencies vii) Temporary assistance for needy families, aged, blind, or disabled assistance viii) Pregnant women assistance benefits ix) Poverty-related veteran’s benefits x) Refugee resettlement benefits xi) Supplemental Social Security Income (SSI) xii) Social Security Disability Income (SSDI) xiii) Retirement documents such as pension. xiv) Military Disability letter with percentage and amount received Appendix- B Appeal Form for Veterans Relief Fund Veteran or person appealing the Veteran Relief Fund decision

Name:

Last First

What is being appealed:

Why is this decision being appealed:

Attach additional sheets if needed Decision made by Veteran Advisory Board (VAB):

Date:

Chairman of the Board Health Department Director

Board Member Board Member Board Member

Board Member Board Member Board Member