McHenry County Veterans Assistance Commission

Nathaniel R. Johnson
Superintendent

COUNTY GOVERNMENT CENTER
667 Ware Road, Suite 100
Woodstock, IL 60098
Phone: (815) 334-4229
Fax (815) 334-4678

Use these instructions, the attached Notice of Rights and Responsibilities, and the attached application to apply for Veterans Assistance. Section II of this application contains a Memorandum of Understanding outlining the expectations and responsibilities of the applicant and the Veterans Assistance Commission. Section III of this form notifies you of your rights and responsibilities as it applies to the Veterans Assistance Program.

Please answer all questions in Sections III through Section VIII of this application. Be sure you, and if applicable your spouse, signs this application before you submit it.

When submitting this application, be sure to include a copy of each one of your DD-214's (military separation papers), a copy of your marriage certificate if applicable, a copy of dependency documents such as birth certificates or adoption decrees for children if applicable, a copy of your government-issued photo identification card with a current McHenry County address, and a copy of your spouse's government-issued photo identification card with a current McHenry County address if applicable. Submit your application and those documents in person during normal business hours, by mail, or by fax to:

Veterans Assistance Commission of McHenry
County 667 Ware Road, Suite 100
Woodstock, IL 60098

Fax: (815) 334-4678

If you mail or fax your application, be sure to call our office at (815) 334-4229 to ensure that we received it.

NOTE: Before signing this form, please understand that the Veterans Assistance Commission of McHenry County (VACMC) provides a valuable service to the veteran, widows, and specific dependents of this county. Abuse of any services provided by this office will not be tolerated. This document is effective for one year.

VETERANS FINANCIAL ASSISTANCE: I (we) fully understand that failure to report or disclose all necessary documentation pertaining to proof of veteran status, sources of income, expenses, other data requested by the VACMC, state or federal law, may result in the denial nial of financial assistance. I (we) fully understand that it is unlawful to misrepresent facts in order to present oneself as an eligible claimant.

ADVOCACY BEFORE THE US DEPARTMENT OF VETERANS AFFAIRS OR OTHER GOVERNMENTAL BODIES: I (we) understand that all information presented in support of a claim with the US Department of Veterans Affairs is true and correct to the best of my (our) knowledge. The VACMC reserves the right to refuse to represent a claim it sees as clearly fraudulent or frivolous. In such cases the VACMC may assist the claimant in representing him or herself. I (we) have been informed that anytime the recipient of benefits from the VBA submits a new claim the VBA may find errors in earlier decisions resulting in reducing or discontinuing a benefit or may determine that a condition had improved. I (we) agree to hold the VACMC free of all liabilities should the VBA deny, reduce, or discontinue benefits for this or previously adjudicated claims. Additionally, it is understood that a copy of the claim application and/or any information resulting from a verification process shall be furnished upon request.

CONSENT TO SHARE INFORMATION: By signing I (we) certify that all information presented to the VACMC is true, correct and complete; and, I (we) understand that by applying for assistance from the VACMC, information may be shared with other local, state, or federal agencies in an effort to coordinate services on my (our) behalf. Recipients of financial assistance will have their information shared with their Township Administrator of General Assistance.

1. Veterans Financial Assistance programs are not designed to be an ongoing financial supportive program over any substantial amount of time. Veterans Financial Assistance is to help a veteran family while a longer-term solution to the financial stress is found.

2. You have the right to apply for Veterans Assistance at the VAC office located at the McHenry County Government Center Administration Building, 667 Ware Road, Woodstock IL 60098. The VAC phone number is 815-334-4229. Office hours are from 8:00am - 4:30pm. Outreach may be available for certain disabled applicants.

3. Veterans Financial Assistance programs may only be granted in accordance to the written guidelines for this VAC's programs. It is the responsibility of the recipient to request an appointment with a Veterans Service Officer to establish continued eligibility for assistance

4. It is also the applicant's responsibility to arrive to a scheduled appointment on time with all necessary documentation.

5. You have the right to be treated with courtesy, consideration, and respect by all our staff. You are responsible to treat VAC staff with the same respect. If you feel that you have not been treated in such a way you have the right to file a complaint with the Veterans Assistance Commission of McHenry County (VACMC).

6. You must cooperate with the VAC staff by immediately informing them of any changes which occur in your financial or living situation.

7. You must follow through with all the referrals that have been provided by the VACMC which may mean meeting with referred agencies in person and providing the VAC with a completed referral form.

8. You have the right to view the Handbook Guide of Services Provided Rules and Eligibility Standard either in the VAC office or on the internet via our website.

9. You have the right to ask questions about your case and to examine your own case file by appointment in the presence of an authorized VAC Veteran Service Officer.

10. You have the right to appeal decisions that reduce or deny Financial Assistance.

11. Veterans Financial Assistance programs administered by the VACMC are only available to eligible veterans or their surviving dependents who legally reside within the boundaries of McHenry County IL.

NOTE: If married, you should provide a copy ofyour marriage certificate with this application. Ifwidowed, youshould provide a copy of your spouse's death certificate with this application. If divorced, you should provide a copy of your divorce decree with this application. If separated, you should provide a copy of your legal separation papers with this application. If you need help obtaining these documents, call the County office where the documents were filed.

(If "Married, "complete Boxes 10 through 15. Otherwise skip to Box 16.)

NOTE: If you have dependent children you should provide birth certificates and/or adoption decrees for all of your dependent children. If you need help obtaining these documents, call the County office where the documents were filed.

NOTE: You must submit a DD-214 or equivalent document for each period of active duty service. If you do not have your DD-214, call our office for help obtaining one.

If "Yes, "state the name of your employer and skip to Box 21:

Please ensure that your application is complete and that you, and if applicable your spouse, reads and signs this certification. By signing below you, and if applicable your spouse, certify that:

1. All of the information listed on this application is true and correct to the best of your knowledge and belief.

2. You understand that if you did not provide full or correct information on this application you may be required to repay any Veterans Assistance benefits received either voluntarily, through court order, or through the Illinois Local Debt Recovery Program

3. You understand that if you provide fraudulent information to obtain Veterans Assistance benefits you will be reported to the McHenry County Sherriff's Office for investigation and prosecution.

4. You have received a Notice of Rights and Responsibilities which are listed in Section II of this application.

5. You authorize the release of any information from any person, entity, organization, agency, service provider, or employer that the Veterans Assistance Commission of McHenry County determines is required to make a determination on your application for Veterans Assistance.