Fillable AFRH PRE-ADMISSIONS CHECKLIST (Armed Forces Retirement Home)

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AFRH PRE-ADMISSIONS CHECKLIST (Armed Forces Retirement Home)

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AFRH PRE-ADMISSIONS CHECKLIST
Armed Forces Retirement Home, 3700 North Capitol St. NW, PAO Box 584, Washington DC 20011
Fax Number (202) 541 7519
The following items are needed when submitting an application:
AFRH APPLICATION FORM including Medical Release Form - completed and signed by the applicant
AFRH MEDICAL EXAMINATION FORM with current PPD test results (tuberculosis) - completed by Primary Care Physician
AFRH FUNCTIONAL ASSESSMENT FORM completed by a licensed occupational or physical therapist
DD-214 submit FINAL DD-214 with TOTAL years of service from all Military Branches (Submit COPY – not original)
FOR ELIGIBLE COUPLES APPLYING: Each person must qualify for residency either as a veteran or as a beneficiary spouse
Each person must submit their own Application, Medical Exam, & Functional Assessment
Beneficiary spouse: submit Marriage Certificate confirming they married BEFORE sponsor retired from active service
REQUIRED HEALTH INSURANCE: Submit a Copy of the Insurance ID cards or Military ID for Tricare (both sides)
MEDICARE ELIGIBLE (AGE 65 & UP)
NOT MEDICARE ELIGIBLE (UNDER 65)
MEDICARE: PART A AND PART B (MANDATORY)
MAJOR HEALTHCARE INSURANCE - MANDATORY (select one)
MEDICARE SUPPLEMENTAL INSURANCE (select one)
Tricare (Prime / Select / Retired Reserves)
Tricare (TFL Or Prime)
Medicare Advantage
Private medical insurance
Medicaid
100% VA Benefits
Medicare Supplement
Healthcare Marketplace (public)
100% VA Benefits
BANK STATEMENTS 2018 & 2019: All applicants must submit bank statements verifying insurance, disability
compensation, other taxable & non-taxable income/benefits as well as expenses for fee assessment purposes.
3 bank statements from 2018 & 2019 - any 3 consecutive months from each of these years
Current bank statement to verify no increase in award or percentage
DEPT. OF VETERANS AFFAIRS (DVA) COMPENSATION: Verification is required for ALL veterans (select one)
BENEFITS SUMMARY LETTER with current Percentage (%) Rating; or
NO BENEFITS SUMMARY LETTER verifying zero compensation ($0)
To obtain letter confirming VA Benefits call 1-800-827-1000 or go online www.va.gov to print copy.
FILED INCOME TAX RETURNS FOR 2018 & 2019: Required for all applicants (select one)
Copy of IRS 1040 Tax Returns for last 2 years: Either submit proof Electronic Submission or IRS Transcript
Copy of IRS Non-filing Letter: For applicants who did not file tax returns in the last 2 years
To obtain Transcript/Non-filing Letter at www.irs.gov or 800-908-9946)
IRS 1099 & W-2 FORMS: submit copies for income in 2018 & 2019 from any of the following or other sources
DFAS Form 1099R – Military Retirement, Pension
OPM Form 1099R – Civil Service Retirement, Pension
SSA Form 1099 – Social Security Benefits
Form 1099 – TSP (Thrift Savings Plan), Employee Retirement Plans, Pensions, Annuities, or IRAs
Form 1099-INT Interest Income
Form 1099-DIV Dividend Income
Form W-2 Wages / W-2G Gambling / Rental Income
Any Other Income Sources (business, profits, etc.)
DFAS RETIREE ACCOUNT STATEMENT (RAS): Verify any compensation from SURVIVORS BENEFIT PLAN (SBP), COMBAT RELATED
SPECIAL COMPENSATION (CRSC), CONCURRENT RETIREMENT DISABILITY PAY (CRDP), OR MILITARY PENSION - (if applicable)
Most recent annual DFAS Retiree Account Statement (or if RAS is not available, income verified on bank statements)
To obtain call DFAS 800-321-1080 or visit website www.dfas.mil to print most recent statement through myPay
ALIMONY/CHILD SUPPORT if applicant is currently responsible for ongoing court ordered support payments
Copy of the official Court Order
Publish Date: 04/15/20
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If notified by the ADMISSIONS office of an official REPORT date, please bring the following items
with you:
Voided Check for Electronic Funds Transfer (EFT) of Monthly Resident Fee (EFT is required for fee payment)
Current Last Will and Testament and Executor of Estate
Current Living Will; Durable Power of Attorney (POA) for Healthcare
Durable Power of Attorney (POA) for Finance
Pre-Paid Pre-Arranged Funeral Plans
Emergency Contacts, Next of Kin, Executor & Powers of Attorney: Full names, addresses, phone numbers, emails, etc.
REAL ID-compliant ID or driver’s license, vehicle registration & automobile insurance. Bring official documentation to
update the state of residency on your ID or driver’s license and for registering your vehicle (if bringing a vehicle to AFRH).
The REAL ID Act establishes minimum security standards for license issuance and production and prohibits Federal agencies from
accepting for certain purposes (such as flying on a commercial flight) driver’s licenses and identification cards from states not meeting
the Act’s minimum standards. For more information about REAL ID requirements and whether or not your current ID meets these
established guidelines please go to the following websites:
Washington, DC: https://dmv.dc.gov/page/real-id-faqs
Gulfport, MS: https://www.dhs.gov/real-id/mississippi
Copy of medical records for last 12 months. Notify us in advance if you receive oxygen therapy.
CONTACTS FOR FINANCIAL DOCUMENTS FOR AFRH BUSINESS CENTER
DESCRIPTION
HOW TO OBTAIN IF MISSING
INCOME
TAXES
1040
Tax Return – if required to file
(Tax Prep help is available at AFRH)
IRS: 1-800-829-1040
For a tax transcript call your tax preparer
Any 1099’s
Social Security, Interest, All sources of Retirement
Income including DFAS
Contact the Issuer:
Social Security:
DFAS:
PenFed:
1-800-772-1213
1-888-332-7411
1-800-225-6378
Any W-2’s
Any Wages Earned from Employment
Contact your employer for this information
VA
Any Benefits
(for new applicants)
Determination Letter and if applicable provide the
statement of benefits received
Veterans Affairs (VA): 1-800-827-1000
EXEMPT
MISC.
Stipend – AFRH
Payment from AFRH for volunteering time at the
home
NOT NEEDED
Capital Gain/Loss
(Form 8949)
Gains or Losses reported on IRS Form 8949
IRS: 1-800-829-1040
(or call your tax preparer for this information)
One-Time Exemption
For 1099-INT if proof of funds have been moved
to an account that cannot be accessed for at least
a year (CD’s, Annuities, etc.)
Contact your bank or other Financial
Institution
DECUCTIONS
MEDICAL
Medicare Part A
Hospital Insurance: Most individuals receive Part
A automatically at age 65
Contact for more information:
1-800-633-4227 (1-800-MEDICARE)
Medicare Part B
Medical Insurance: Can be found on Social
Security 1099
Contact for more information:
1-800-633-4227 (1-800-MEDICARE)
Tri-Care Prime
Any premiums paid for Tricare Prime Health or
Dental Insurance
(provide 3 consecutive monthly bank statements)
Contact your bank or other Financial
Institution
Supplemental Health
Insurance
If 100% service related disabled, any health or
dental insurance premiums may be deducted
(provide 3 consecutive monthly bank statements)
Contact your bank or other Financial
Institution
MISC.
Child/Spousal
Support
Must provide a copy of the court order as well as
proof of payment (such as Letter from Court, Bank
statement/transaction)
Contact the Court and your bank or other
Financial Institution
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AFRH PRE-ADMISSIONS CHECKLIST (Armed Forces Retirement Home)

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Completed 18 July 2020

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