(608) 266-1311 | 1-800-WIS-VETS (947-8387)
COUNTY TRANSPORTATION GRANT APPLICATION – SUPPLEMENT
2016-2017 / County Veterans Transportation Services Report
I. Number of veterans transported and miles driven
# Rides x # Miles - 2016 / JUL / AUG / SEP / OCT / NOV / DEC / 2016 TOTAL
# Rides x # Miles - 2017 / JAN / FEB / MAR / APR / MAY / JUN / 2017 TOTAL
II. Revenue and expenses related to veteran’s transportation services
2016 / 2017
Transportation Service Expenses / Jul-Dec / Jan-Jun / Total
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
Totals / $ / $ / $
Transportation Service Revenues
Ride Fees / $ / $ / $
Other / $ / $ / $
Totals / $ / $ / $
WDVA 0000 (02/07) Page 2 of 1 You can access the most recent version of this form
W:\Templates\WDVA_0000.dot from the WDVA website at www.WisVets.com/Forms.