PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
• Gross annual income from employment, except for income from your farm, ranch, property or business. Include your wages, bonuses,
tips, severance pay and other accrued benefits and your child's income information if it could have been used to pay your household
• Net income from your farm, ranch, property, or business.
• Other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability income,
compensation benefits such as VA disability, unemployment, Workers and black lung, cash gifts, interest and dividends, including tax
exempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities.
Section VI - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children
Do Not Report:
Donations from public or private relief, welfare or charitable organizations; Supplemental Security Income (SSI) and need-based payments
from a government agency; profit from the occasional sale of property; income tax refunds, reinvested interest on Individual Retirement
Accounts (IRAs); scholarships and grants for school attendance; disaster relief payments; reimbursement for casualty loss; loans; Radiation
Compensation Exposure Act payments; Agent Orange settlement payments; Alaska Native Claims Settlement Acts Income, payments to
foster parent; amounts in joint accounts in banks and similar institutions acquired by reason of death of the other joint owner; Japanese
ancestry restitution under Public Law 100-383; cash surrender value of life insurance; lump-sum proceeds of life insurance policy on a
Veteran; and payments received under the Medicare transitional assistance program.
Section VII - Previous Calendar Year Deductible Expenses
Section VIII - Consent to Copays and to Receive Communications
Report non-reimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care, drugs, eyeglasses,
Medicare, medical insurance premiums and other health care expenses paid by you for dependents and persons for whom you have a legal
or moral obligation to support. Do not list expenses if you expect to receive reimbursement from insurance or other sources. Report last
illness and burial expenses, e.g., prepaid burial, paid by the Veteran for spouse or dependent(s).
By submitting this application, you are agreeing to pay the applicable VA copayments for care or services (including urgent care) as
required by law. You also agree to receive communications from VA to your supplied email, home phone number, or mobile
number. However, providing your email, home phone number, or mobile number is voluntary.
Submitting Your Application
Where do I send my application?
Mail the original application and supporting materials to the Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section
3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it
displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This includes the
time it will take to read instructions, gather the necessary facts and fill out the form.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1705,1710, 1712, and 1722 in order for VA to
determine your eligibility for medical benefits. Information you supply may be verified from initial submission forward through a computer-matching program.
VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the
Privacy Act systems of records notices and in accordance with the VHA Notice of Privacy Practices. Providing the requested information is voluntary, but if any
or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will
not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA
benefits. VA may also use this information to identify Veterans and persons claiming or receiving VA benefits and their records, and for other purposes
authorized or required by law.
You or an individual to whom you have delegated your Power of Attorney must sign and date the form. If you sign with an "X", 2
people you know must witness you as you sign. They must sign the form and print their names. If the form is not signed and dated
appropriately, VA will return it for you to complete.
Attach any continuation sheets, a copy of supporting materials and your Power of Attorney documents to your application.
Section V - Employment Information:
PAGE 2 OF 5VA FORM 10-10EZ, JAN 2020
• Veterans Employment Status
• Date of Retirement
• Company Name
• Company Address
• Company Phone Number