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Step 1: Before You Start . . . What is VA Form 10-10EZ used for? - page 5 / 5

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APPLICATION FOR HEALTH BENEFITS, Continued SECTION VI - FINANCIAL DISCLOSURE VETERAN'S NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

Disclosure allows VA to accurately determine whether certain veterans will be charged copayments for care and medications, their eligibility for other services and enrollment priority. Veterans are not required to disclose their financial information; however, VA is not currently enrolling new applicants who decline to provide their financial information unless they have a special eligibility factor. Recent combat veterans (e.g., OEF/OIF) who were discharged within the past 5 years or were discharged more than 5 years ago and applying for enrollment by Jan. 27, 2011 are eligible for enrollment without disclosing their financial information but like other veterans may provide it to establish their eligibility for travel reimbursement, cost-free medication and/or medical care for services unrelated to military experience.

No, I do not wish to provide financial information in Sections VII through X. I understand that VA is not enrolling new applicants who do not provide this information and who do not have a special eligibility factor (e.g., recently discharged combat veteran, compensable service connection, receipt of VA pension or Medicaid benefits.) If I am enrolled, I agree to pay applicable VA copayments. Sign and date the form in Section XII.

Yes, I will provide my household financial information for last calendar year. Complete applicable sections VII through X . Sign and date the form in Section XII.

SECTION VII - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)

1. SPOUSE'S NAME (Last, First, Middle Name)

2. CHILD'S NAME (Last, First, Middle Name)

1A. SPOUSE'S MAIDEN NAME

Son Daughter 2A. CHILD'S RELATIONSHIP TO YOU (Check one) Stepson

Stepdaughter

1B. SPOUSE'S SOCIAL SECURITY NUMBER

2B. CHILD'S SOCIAL SECURITY NUMBER

2C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)

1C. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)

1D. DATE OF MARRIAGE (mm/dd/yyyy)

2D. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP )

2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?

YES

NO

2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST

CALENDAR YEAR?

YES

NO

3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR ENTER THE AMOUNT YOU CONTRIBUTED TO THEIR SUPPORT.

SPOUSE

$

CHILD

$

2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials) $

SECTION VIII - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN

(Use a separate sheet for additional dependents)

VETERAN

SPOUSE

CHILD 1

1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips, etc.) EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS

$

$

$

  • 2.

    NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS

  • 3.

    LIST OTHER INCOME AMOUNTS (eg., Social Security, compensation, pension

interest, dividends). EXCLUDING WELFARE.

$ $

$ $

$ $

SECTION IX - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES

1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists, medications, Medicare, health insurance, hospital and nursing home) VA will calculate a deductible and the net medical expenses you may claim.

$

2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES FOR YOUR DECEASED SPOUSE OR DEPENDENT CHILD (Also enter spouse or child's information in Section VII.)

$

3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books, fees, materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.

$

SECTION X - PREVIOUS CALENDAR YEAR NET WORTH (Use a separate sheet for additional dependents)

VETERAN

SPOUSE

CHILD 1

1. CASH, AMOUNT IN BANK ACCOUNTS (e.g., checking and savings accounts, certificates of deposit, individual retirement accounts, stocks and bonds)

2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS. (e.g., second homes and non-income producing property. Do not count your primary home.)

$ $

$ $

$ $

3 . V A L U E O F O T H E R P R O P E R T Y O R A S S E T S ( e . g . , a r t , r a r e c o i n s , c o l l e c t a b l e s ) M I N U household effects and family vehicles. S T H E A M O U N T Y O U O W E O N T H E S E I T E M S . I N C L U D E V A L U E O F F A R M , R A N C H O R B U S I N E S S A S S E T S . E x c l u d e

$

$

$

SECTION XI - CONSENT TO COPAYMENTS

If you are a 0% SC veteran and do not receive VA monetary benefits or a NSC veteran (and you are not a Former POW, Purple Heart Recipient or VA pensioner) and your household income (or combined income and net worth) exceeds the established threshold, this application will be considered for enrollment, but only if you agree to pay VA copayments for treatment of your NSC conditions. If you are such a veteran by signing this application you are agreeing to pay the applicable VA copayments as required by law.

SECTION XII - ASSIGNMENT OF BENEFITS

I understand that pursuant to 38 U.S.C. Section 1729, VA is authorized to recover or collect from my health plan (HP) for the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for my medical care, including benefits otherwise payable to me or my spouse.

ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.

SIGNATURE OF APPLICANT

DATE

VA FORM JUL 2008

10-10EZ

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