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Cover Page
APPLICATION FOR
ADMISSION
If FAXING documents to AFRH, please make a
black & white copy before sending the fax so
that it will be legible when it arrives. Please call
and let us know to look for the documents to
come through as well – Thank you for all your
help! We want to prevent any delays in pro-
cessing applications.
RETURN APPLICATION FORMS TO:
THE ARMED FORCES RETIREMENT HOME
PUBLIC AFFAIRS OFFICE #584
3700 NORTH CAPITOL ST, NW
Washington, DC 20011-8400
Fax Number: (202) 541-7519
Telephone: (800) 422-9988
Prior Versions No Longer
APP
Dear Applicant:
Please complete the following steps:
1. Complete the Application Form and submit
your military documentation and health
insurance information including a copy of
your DD-214, Retiree Military ID (if avail-
able), Insurance ID
cards, and VA Benefits
letter.
2. Submit all medical review forms including
the Medical Release Form, Medical Exam-
ination, and Functional Assessment.
3. Submit financial information included in this
application along with documentation re-
quested on the Pre-Admissions Checklist. If
additional information
for the fee assess-
ment is required, a member of the business
office will contact the applicant directly.
4.
Additional information may be requested
by the medical review board depending
on
conditions reported on
the medical exam
or
functional assessment. Individuals with
any history
of cognitive, psychiatric, or
substance use concerns may be asked to
submit a Mental
Health Evaluation form.
Some individuals may be asked to come to
AFRH for an on-site evaluation to be seen
by the medical staff in person.
5.
If the application is cleared through the pre-
admissions review, the admissions officer at
the selected location (DC or GP) will contact
you
to arrange a report date and let you
know what to bring with you upon arrival.
6. All applicants will have a medical evaluation
upon arrival. An applicant may not be
admitted to AFRH if he/she lacks the ability
to live independently when they arrive or if
there is any other cause for delay or denial;
therefore, please plan ahead in case you are
not able to be admitted to the Home on the
scheduled report date.
If you receive notification that your application has
been approved, you must wait until the Admissions
office arranges an official report date with you. Do
not make moving arrangements without an official
report date, please.
Valid
APP 03-2021
ARMED FORCES RETIREMENT HOME
Application for Admission
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C 136, Under Secretary of Personnel and Readiness; 24 U.S.C. 401, Armed
Forces Retirement Home; DoD Directive 5124.09 Assistant Secretary of Defense for Personnel
and Readiness Force Management; DoD Instruction 1000.28, Armed Forces Retirement Home
(AFRH); and E.O. 9397 (SSN), as amended.
PURPOSE: To determine and verify eligibility for admission to the AFRH.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the
Privacy Act of 1974, as amended, the records contained herein may specifically be disclosed
outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: To the Federal
Reserve for processing the debt on the resident account; To authorized contractors or vendors for
the purpose of providing medical services to the residents of the Armed Forces Retirement Home;
To any Federal agency which provides medical services to residents of the Armed Forces
Retirement home; To the Inspector General of the Department of Defense or his/her designee, for
conducting inspections of AFRH records; To a Federal agency, or an organization or person
contracting with the AFRH for information needed in the performance of official duties related to
reconciling or reconstructing data files, compiling descriptive statistics, and/or making
analytical or financial studies to support the function for which the records were collected and
maintained; Law Enforcement Routine Use; Congressional Inquiries Disclosure Routine Use;
Disclosure of Information to the National Archives and Records Administration Routine Use;
Disclosure to the Merit Systems Protection Board Routine Use; and Data Breach Remediation
Purposes Routine Use.
The applicable system of records notice is DPR 38 DoD, Armed Forces Retirement Home
electronic Resident Information System (eRIS).
DISCLOSURE: Voluntary; however, failure to provide the required information may result in the
delay or denial of admission.
Warning: Please print and MAIL or FAX your application documents to the Public Affairs Office.
Information in this application is Protected Personal Information and should not be sent
electronically without proper protection in place (such as password protection). Emailed
documents are more vulnerable to unintended disclosure to inappropriate recipients if not
protected. Please call the Public Affairs Office and speak to a representative if you have any
questions regarding the proper procedures for submitting applications to AFRH at 800-422-9988.
MAIL TO: (preferred method for shipping – USPS: United States Postal Service)
Armed Forces Retirement Home
Public Affairs Office Box #584
3700 North Capitol St, NW
Washington, DC 20011-8400
FAX TO: (please call first to confirm that there is a PAO representative present 7am – 5pm EST)
Public Affairs Office (202) 541-7698 or (202) 541-7551
Fax Number (202) 541-7519
Cover Page
Prior Versions No Longer Valid
APP 03-2021
ARMED FORCES RETIREMENT HOME
ƉƉůŝĐĂƚŝŽŶĨŽƌĚŵŝƐƐŝŽŶ
For Employee Use
➀➁➂➃➄ⒶⒼⓌ
PAOIN: _________________________
PAOCLR: _________________________
ĂƚĞ^ƵďŵŝƚƚĞĚ͗ __________________________ ŶƚŝĐŝƉĂƚĞĚŶƚƌLJ͗ __________________________
If any of the statements below is false, please call AFRH to discuss before completing the application.
TRUE FALSE 1. Applicant is able to complete activities of daily living without assistance from others.
TRUE FALSE 2. Applicant has never been convicted of a felony.
TRUE FALSE
3. Veteran spent less than half of their service time as a commissioned officer.
How did you learn about AFRH? (Which publication, referral from someone, etc.)
WĞƌƐŽŶĂůWƌŽĨŝůĞʹWƌŝŵĂƌLJƉƉůŝĐĂŶƚ;sĞƚĞƌĂŶͿΘŽͲĂƉƉůŝĐĂŶƚ;^ƉŽƵƐĞͿ
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Full Name (First, Middle/Maiden, Last)
Street
State
Zip Code
Social Security Number
Age
Birthplace
Service Branch
Military Rank/Rate (Retired?)
Pay Grade
Marital Status
Email
Telephone (mobile)
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ŚŽŝĐĞ͗ 'W 
Yes N/A Have you ever applied to AFRH before? If so, when: _________________________________
Yes N/A If you are a former resident, when did you leave? _________________________________
ŽͲƉƉůŝĐĂŶƚ
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Full Name (First, Middle/Maiden, Last)
Street City State Zip Code
Social Security Number Birthdate Age Birthplace
Service Branch (if you were in the military) Beneficiary Spouse? or Rank/Rate? Pay Grade/NA Date of Marriage
Email Telephone (home/landline) Telephone (mobile)
Yes No Are you applying as a EKEͲD/>/dZzOR BENEFICIARY ^WKh^ of a Zd/Z>/'/>sdZE?
Yes
No If so, are you enrolled in Z^ and a dƌŝĐĂƌĞ,ĞĂůƚŚWůĂŶ?
Yes No Did you get married &KZ the veteran sponsor D>/'/>&KZZd/ZWz?
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Clear Form
Clear p.1
ARMED FORCES RETIREMENT HOME
Application for Admission
For Employee Use
➀➁➂➃➄ⒶⒼⓌ
PAOIN: _________________________
PAOCLR: _________________________
ELIGIBILITY FOR ENLISTED PERSONNEL AND NONCOMMISSIONED VETERANS
Enlisted Personnel, Warrant Officers, and/or Limited Duty Officers are eligible if
they qualify under one or more of the following circumstances:
RETIRED VETERANS:
• Active-Duty Career Retired: Veterans who retired with 20 or more years of active-duty service
in a regular component of the Armed Forces.
•
Eligible for Retired Pay: Veterans, who served in a regular or reserve component of the Armed
Forces, who are now eligible to receive retired pay and benefits:
Guard/Reserves with over 20 years of creditable service (combined inactive and active-duty
service) who have reached retirement age.
Veterans who spent less than 20 years in the Armed Forces and qualified for an early
retirement and benefits (i.e. TERA, medical, disability, or other authority).
•
Beneficiary Spouse: The spouse of a retired veteran may apply to live with a Retiree if the
spouse is enrolled as a beneficiary in DEERS (Defense Enrollment Eligibility Reporting System);
and was married to his/her sponsor before the veteran became eligible for retirement from the
Armed Forces.
OTHER ELIGIBLE VETERANS:
•
Service-Connected Disability: Veterans with a service-connected disability rating of 50 percent
or greater from the Dept. of Veteran Affairs.
•
War Theater: Veterans who served in a war theater or received hostile fire pay and suffer from
injuries, disease, or disability (including service-connected disabilities or other conditions
unrelated to military service).
•
WWII Female Veteran: Veterans who served in a women’s component before June 12, 1948
who are determined to be eligible due to compelling personal circumstances.
Primary
Spouse
Eligibility - Select any of the following which are TRUE for either applicant
Served in the Armed Forces (Regular, Reserves, or National Guard)
Over 50% of service spent as an enlisted member, warrant officer, or limited duty officer
Retired after serving on active duty for 20 or more years in a regular component
Retired Guard/Reserves with at least 20 years of creditable service (active + inactive)
Retired early from the military (TERA, disability, medical, etc.)
Service-connected disability with VA rating of 50% or greater
Served in a war theater (listed on DD214)
Received Hostile Fire or Imminent Danger Pay
Currently have a disability, illness, or disease (non-service-related or below 50% VA rating)
Served in a women’s component during WWII
Qualified beneficiary spouse who is enrolled in DEERS (and Tricare)
Married the primary applicant/resident before the veteran became eligible for retired pay
Page | 2 of 8
Prior Versions No Longer Valid
APP 03-2021
Clear p.2
All applicants must also meet the following requirements:
ARMED FORCES RETIREMENT HOME
Application for Admission
⃞ 1. Applicants must have NEVER BEEN CONVICTED OF A FELONY and will be subject to a
background check.
⃞ 2. Applicants must be discharged or released from any military service under honorable
conditions.
⃞ 3. There are no specific military service requirements for a co-applicant spouse who is applying
as the dependent spouse of an eligible retired veteran who
SPENT AT LEAST 50% OF THEIR
TOTAL SERVICE TIME
as an Enlisted Member, Limited-Duty Officer, or Warrant Officer as
long as the spouse is registered as a beneficiary in DEERS and has their own Military ID.
⃞ 4. At the time of admission, ALL applicants must be both PHYSICALLY AND MENTALLY ABLE TO
LIVE INDEPENDENTLY as determined by AFRH medical review. Specifically, one must be able
to manage daily tasks, tend to one’s own personal needs, attend a central dining facility for
meals, arrange for and keep medical appointments, and make reasonable decisions
regarding healthcare, finances, and safety without assistance from others.
⃞ 5. Direct admission to advanced levels of care is NOT available. If an increased level of care is
needed for residents who have already been admitted to the Home; AFRH provides assisted
living, long term care and memory support at both of the AFRH locations.
⃞ 6. Individuals with mental health problems or substance/alcohol use disorders are NOT
ELIGIBLE except upon a judgement and satisfactory determination by AFRH that the person
meets the requirements for an INDEPENDENT LEVEL of care and that any existing health
conditions may be accommodated within the current scope of services provided by the
Armed Forces Retirement Home (location-specific). AFRH is not equipped for continual
observation, evaluation, or treatment of such disorders. If accepted, the person must agree
to and abide by ANY CONDITIONS OF RESIDENCY as may be required by AFRH medical staff
or administration.
⃞ 7. Applicants must maintain ACCEPTABLE HEALTHCARE COVERAGE in order to be eligible for
residency. If eligible for Medicare, it is required that residents have Part A, Part B, and
Supplemental Coverage. Residents who are not eligible for Medicare must either have
creditable medical insurance that covers hospitalization, medical care, transportation, and
prescriptions; or they must have 100% healthcare benefits through the Department of
Veterans Affairs (those who have a VA Disability Rating which is less than 100%, must obtain
an insurance policy to satisfy this requirement).
⃞ 8. Residents are not required to submit pharmaceutical insurance when initially admitting into
Independent Living; however, PRESCRIPTION INSURANCE IS MANDATORY for residents in
upper levels of care. Residents in assisted living, memory support, or long-term care will
either need to acquire or have prescription coverage in place. Residents without drug
coverage or those who use 100% VA Benefits as their sole form of supplementary
healthcare coverage must obtain an INSURANCE POLICY that covers prescription drugs
upon transfer to an advanced level of care at AFRH.
I have read and understand that approval of my application is predicated upon my ability to
meet all eligibility requirements.
[Please Initial]
________ Primary Applicant
________ Co-Applicant/Spouse
Page | 3 of 8
Prior Versions No Longer Valid
APP 03-2021
Clear p. 3
ARMED FORCES RETIREMENT HOME
Application for Admission
Health Insurance Requirements
Primary Applicant
Name:
Co-Applicant (Spouse)
Name:
Medicare:
All applicants over age 65 must have both Medicare A & B and supplemental health coverage
.
Please refer to your Medicare ID card for the following requested information:
Medicare ID#: ____________________
Part A Effective Date: ____________________
Part B Effective Date: ____________________
Not Eligible (under age 65)
Medicare ID#: ___________________
Part A Effective Date: ___________________
Part B Effective Date: ___________________
Not Eligible (under age 65)
Tricare: Retired Veterans and Beneficiary Spouses who are eligible for TRICARE. Please refer to your Military
ID Card for the following information. Look on front for DoD ID# and back for expiration/coverage information.
Tricare Health Plan:
Not Eligible for Tricare
Tricare Health Plan: Not Eligible for Tricare
Tricare for Life
Tricare Prime/Select
Tricare for Life Tricare Prime/Select
Retired Reserve
US Family Health Plan
Retired Reserve
US Family Health Plan
DoD ID# (DEERS#):
________________________
DoD ID# (DEERS#):
______________________
Effective Date:
________________________
Effective Date: ______________________
Expiration Date:
________________________
Expiration Date:
______________________
CARE AUTHORIZED AT MILITARY TREATMENT/CIVILIAN FACILITIES: CARE AUTHORIZED AT MILITARY TREATMENT/CIVILIAN FACILITIES:
Direct (MTF’s) Civilian (Non-MTF’s)
Direct (MTF’s) Civilian (Non-MTF’s)
Health Insurance Policy:
Individuals, who do not have Tricare or 100% VA Benefits, must have a
supplemental health insurance policy. Please refer to your Insurance ID Card for the following information:
Insurance Co.: __________________________ Insurance Co.: __________________________
Group/Policy #: __________________________ Group/Policy #: __________________________
Effective Date: __________________________ Effective Date: __________________________
Prescription Coverage: Yes No Prescription Coverage: Yes No
Veteran Affairs Benefits:
Veterans with 100% service-connected disabilities may use VA Benefits as
supplemental health coverage. Your VA Benefit Summary Letter will confirm eligibility and percentage rating.
Eligible for VA Healthcare:
Yes No
VA Percentage Rating:
______________________
Eligible for VA Healthcare:
Yes No
VA Percentage Rating:
____________________
Note: Veterans with less than 100% VA Rating must have an INSURANCE POLICY to satisfy the coverage requirements for
AFRH, even if the veteran usually uses the VA for healthcare services. If benefits are insufficient to meet AFRH requirements,
the application status will remain pending until the candidate is able to obtain creditable health insurance.
Page | 4 of 8
Prior Versions No Longer Valid
APP 03-2021
Clear p. 4
ARMED FORCES RETIREMENT HOME
Application for Admission
Military Record Requirements
.
.
.
.
.
.
Each individual who served in the Armed Forces must submit copies of their own military records and proof of eligibility
such as the final DD214, Notification of Eligibility for Retired Pay, NGB22/23, NAVPERS 563, WD AGO 53-55, Discharge
Certificates, Statements of Service, Veterans Affairs Benefits, etc. Spouses who did not serve may leave section blank.
Primary Applicant
Co-Applicant (Spouse)
Honorable
Conditions
Other than
Honorable
Honorable
Conditions
Other than
Honorable
Branch of Service:
Select all Regular, Reserve, and National Guard components in which you served
USA
USAF
USN
USNR
USA
USAF
USN
USNR
USAR
USAFR
USMC
USMCR
USAR
USAFR
USMC
USMCR
ARNG
ANG
USCG
USCGR
ARNG
ANG
USCG
USCGR
Entry into Service:
Describe when and where you entered into military service – Find information on your initial DD214
Initial Service Branch
Date of Entry
Location where Entered
Separation from Service:
Describe how, when, and where you separated from military service – Find information on your final DD214
What type of separation was listed on final DD214 – Retired, Transferred to Reserves, Released, etc.
Total Service Time:
How long did you serve on Active-Duty (Regular Components) or Inactive-Duty (Guard/Reserves)?
If you received a commission during your years of service, please indicate when you received it.
Total ACTIVE-DUTY Time
Total INACTIVE-DUTY Time
Date of Commission
Retirement:
If you qualify for retired pay and benefits, select type of retirement that applies. Full 20y active-duty career
retired, 20y creditable service in the Guard/Reserves, or early retirement (TERA/DISABILITY)
NGR w/ 20y creditable service
NGR w/ 20y creditable service
Over 20y ACTIVE-DUTY Service
Early Retirement(TERA/Disability)
Not Eligible for Retirement
Not Eligible for Retirement
Date of Retirement:
War Theaters/Hostile Fire Pay
Did you serve during any periods of war declared by Congress? If so, did you serve inside a war theater
or qualify for hostile fire pay?
Did you serve in a War Theater or qualify for HFP?
Yes No
Yes No
WWII
Korea
Grenada
Afghanistan
WWII
Korea
Grenada
Afghanistan
Iraq
Vietnam
Gulf War
Other Conflict
Iraq
Vietnam
Gulf War
Other Conflict
Awards/Medals
Are you the recipient of any distinguished services medals, awards, campaign ribbons, etc.?
Wounded Warrior Program
Prisoner of War
Wounded Warrior Program
Prisoner of War
Silver Star
Service Cross
Medal of Honor
Silver Star
Service Cross
Medal of Honor
Bronze Star
Theater/Campaign:
Bronze Star
Theater/Campaign:
Over 20y ACTIVE-DUTY Service
Early Retirement(TERA/Disability)
Initial Service Branch
Date of Entry
Location where Entered
Final Service Branch
Date of Separation
Location where Separated
Type of Separation
Military Service Number
Character of Service
Total ACTIVE-DUTY Time
Total INACTIVE-DUTY Time
Date of Commission
Military Service Number
Character of Service
Final Service Branch
Date of Separation
Location where Separated
Type of Separation
Date of Retirement:
Did you serve in a War Theater or qualify for HFP?
Final RATE or RANK (CPO, SGT, etc.)
Final RATE or RANK (CPO, SGT, etc.
Final Pay Grade (E-0 to O-10)
Final Pay Grade (E-0 to O-10)
Page 5 of 8
Prior Versions No Longer Valid
APP 03-2021
Clear p.5
For Employee Use
ARMED FORCES RETIREMENT HOME
➀➁➂➃➄ⒶⒼⓌ
Application for Admission
BCSCAN: ________________________
BCCLRD: _________________________
FINANCIAL AND OTHER INFORMATION
Disability Benefits
PRIMARY
SPOUSE
REFER TO VA BENEFIT STATEMENTS, SOCIAL SECURITY BENEFIT STATEMENTS, & DFAS RETIREE STATEMENTS
VA Disability benefits awarded for service-connected conditions %Rating:
VA Service-Connected Disability Income
$
$
VA Disability benefits for Retirees for service-connected conditions incurred during combat
CRSC: Combat-Related Special Compensation
$
$
Disability benefits for Military Retirees (w/ 20+ years) who have a VA disability rating over 50%
CRDP: Concurrent Retirement and Disability Payments
$
Disability benefits only available for disabled low-income Veterans who served during wartime
VA Pension (see VA Benefits Summary) NOTE: This is not the same thing as retirement pay
$
Social Security benefits for individuals who are permanently disabled and unable to work
SSDI/SSI: Social Security Disability Benefits
$
Income Verification
REFER TO IRS FORMS, SOCIAL SECURITY BENEFIT LETTERS, DFAS STATEMENTS, OTHER STATEMENTS
Social Security Benefits/Retirement
DFAS Military Retirement Pay
Civil Service Retirement/Annuity
Other Retirement Income: IRAs, TSPs, Retirement, Pension, Annuity, etc.
Earned Income: employment, contracts, businesses, or services offered
Rental Income, Gambling, or Alimony
Investments/Dividends/Interest
Other:
Insurance Premiums Paid - List Insurance Companies
Dental Insurance Premiums:
Medicare Part B/D Premiums:
Other Health Insurance Premiums Paid:
Financial Management / Legal Affairs - Give names/details
Do you manage your own financial affairs? Who:
Do you have a Conservator, Power of Attorney, or Guardian for your affairs?
Do you have a Living Will/Advance Directive? POA:
Do you have pre-arranged paid Funeral Plans? Where:
Did you file (or will you file by April 15
th
) taxes in the past two years?
Do you have a Last Will and Testament? Executor:
Do you have any court ordered support obligations (alimony, child support, etc.)?
PRIMARY
$
$
$
$
$
$
$
$
PRIMARY
$
$
$
PRIMARY
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
SPOUSE
$
$
$
$
$
$
$
$
SPOUSE
$
$
$
SPOUSE
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Page | 6 of 8
Prior Versions No Longer Valid
APP 03-2021
$
$
$
Clear p. 6
ARMED FORCES RETIREMENT HOME
Application for Admission
FINAL CERTIFICATION
I certify that the information in this application is accurate and factual to the best of my
knowledge. I fully understand that any willful attempts to deceive or distort the infor-
mation in my application may result in disapproval; or, if discovered after approval, may
be reason for discharge from the Armed Forces Retirement Home (AFRH).
Signature of the Primary Applicant* Date
Signature of the Co-Applicant* Date
*Signature/Date Required
I hereby authorize the release of my military and medical records from any civilian or U.S.
Government source to the AFRH.
Signature of the Primary Applicant* Date
Signature of the Co-Applicant* Date
*Signature/Date Required
Anyone (other than the applicant), who has assisted in the preparation of this application
must also sign below. A second signature is necessary if the applicant did not fill out the
application by himself or herself.
Name of the person assisting: __________________________________________
Relationship to the applicant: __________________________________________
Signature of the preparer/assistant Date
PRIVACY ACT STATEMENT
The information solicited on this form is authorized by Title 24, United States Code, and
Section 412(c). The primary purpose for the information is to determine and verify eligi-
bility for admission to the AFRH. The information is given on a voluntary basis, but failure
to provide the information requested may result in denial of admission. The information
provided will be used by AFRH employees and authorized representatives and may be
disclosed as permitted by law outside the AFRH.
Page | 7 of 8 Prior Versions No Longer Valid
APP 03-2021
ARMED FORCES RETIREMENT HOME
Application for Admission
MEMORANDUM OF ACKNOWLEDGEMENT
Thank you for submitting your application to the Armed Forces Retirement Home. For
AFRH to process your application, you must acknowledge your understanding that residency is
contingent on your ability to live independently in our dormitory settings. The signed
memorandum is required for your application to be considered in order for it to be forwarded to
the admission board.
It is important that you understand that part of the application includes an evaluation of
your ability to live independently. We reserve the right to deny admission if you are deemed
unable to do so. For this reason, it is imperative that the medical examination and functional
assessment forms included in the application process are filled out and they reflect the true level
of your ability to live independently. Furthermore, we strongly encourage all applicants to visit
the AFRH prior to admission to ensure our community fits your needs.
By signing this acknowledgement, you indicate your understanding that the conditional
approval of your application is not the final determination of acceptance for residency at AFRH.
Final approval for admission is predicated on AFRH's decision to admit you when reporting to live
at AFRH. AFRH reserves the right to delay or deny admission to the Home if it is determined
that you are not able to live independently, if admission may present a risk to the community,
or for any other reason. If at any point, your admission is delayed or denied by AFRH; alternative
arrangements are the sole responsibility of the applicant.
Your signature below further acknowledges that upon approval and prior to becoming a
resident, AFRH will conduct a background check on you to ensure that you have never been
convicted of a felony.
If your application is approved, AFRH will contact you to work on either scheduling your
arrival at the Home or placing your name on a waiting list. Report dates will be assigned in
consultation with you and the Admissions Officer at the facility chosen. Any necessary alteration
to a report date, whether initiated by the applicant or AFRH, will be conveyed to the other party
as soon as possible so that appropriate actions may be taken.
Signature of the Applicant*
Date
*Signature/Date Required
Signature of the Co-Applicant* Date
*Signature/Date Required
Page | 8 of 8 Prior Versions No Longer Valid
APP 03-2021
- -
AFRH PRE-ADMISSIONS CHECKLIST
Armed Forces Retirement Home, 3700 North Capitol St. NW, PAO Box 584, Washington DC 20011
Telephone Number (202) 541 7922 Fax Number (202) 541 7519
PROOF OF ELIGIBILITY: Submit proof of military eligibility, independent health status, and insurance coverage.
AFRH APPLICATION FORM completed and signed by each applicant and all supporting Military Documentation:
DD-214 must submit a copy of FINAL DD-214 with the TOTAL years of service from all Military Branches
Notification of Eligibility for Retired Pay: Retirement Pay for TERA, Disability, and Guard/Reserves (as applicable)
SCD/War Theater: show war theater/hostile fire pay (on DD214) or service-connected disability over 50% (VA Letter)
Beneficiary Spouse: must submit a copy of the spouse's Military ID (proof of enrollment in DEERS) and a copy of their
Marriage Certificate (proof of being married to the sponsor before the veteran retired from the Armed Forces)
AFRH MEDICAL REVIEW FORMS: (any incomplete forms will delay processing - please check over forms prior to submission)
Medical Release Form: Must include all contact information for providers who complete medical/functional exams.
Medical Examination Form: By Primary Care Provider with current TST (Tuberculosis Screening Test) results.
Functional Assessment Form: Must be completed by a licensed Physical/Occupational Therapist.
PROOF OF HEALTH INSURANCE:
MEDICARE ID CARD: Applicants over 65 must be enrolled in both Part A & B. Submit a copy of card (both sides)
M
ILITARY ID CARD: Retired veterans and beneficiary spouses must submit a copy of their own Military ID (both sides)
as proof of enrollment in a TRICARE Health Plan.
H
EALTH INSURANCE ID CARD: A Health Insurance Policy is required for applicants who do not have a TRICARE Health Plan
or 100% VA Benefits. Submit a copy of the health insurance ID card (both sides)
D
ENTAL/DRUG/VISION INSURANCE ID CARDS: If available, please submit copies of IDs if you have these policies (optional)
REQUIRED FINANCIAL DOCUMENTATION: Submit proof of current income for fee assessment purposes
DEPT. OF VETERANS AFFAIRS (DVA) COMPENSATION: Verification is required for ALL veterans (select 1)
BENEFITS SUMMARY LETTER with current Percentage (%) Rating and compensation; or
N
O 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.
BANK STATEMENTS : submit bank statements verifying insurance premiums, disability compensation,
other taxable & non-taxable income/benefits as well as expenses (please highlight relevant income if possible)
2019 2020 2021 (by Apr 15
th
) : 3 consecutive bank statements from each year (9 total)
FILED INCOME TAX RETURNS FOR 2019 & 2020 (by APR 15
th
):
Submit copy of IRS 1040 Tax Returns or proof of non-filing
2019
2020 : IRS 1040 Form - Submit completed Tax Return & proof of electronic filing or an IRS Transcript
2019
2020 : If you haven’t filed taxes, you must submit an Official IRS Non-filing Letter/Transcript
To obtain a Transcript or Non-filing Letter submit Form 4506-T available at www.irs.gov or call 800-908-9946
IRS 1099 & W-2 FORMS: For ANY income in 2019 & 2020 (by FEB 15
th
) from these or any other sources (if applicable)
All IRS 1099s/W-2 Forms are required whether or not you have filed income taxes
2020 : DFAS Form 1099R - Military Retirement Pay
2019
2019
2020 : SSA Form 1099 – Social Security Benefits
2019
2020 : OPM Form 1099R – Civil Service Retirement / Annuity
2019
2020 : Form 1099R, 1099-INT, 1099-DIV, 1099-MISC, etc.
2019
2020 : Form W-2 Wages, Gambling, Rent, etc.
2019
2020 : Any Other Income Sources (business, profits, investments, alimony, etc.)
DFAS R
ETIREE 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)
2019
2020 : Most recent annual DFAS Retiree Account Statement
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 Orders/Documents, and proof of payments/receipts
APP 03-2021
Addendum | Checklist
Prior Versions No Longer Valid
Clear List
If notified by AFRH that your application has been approved, please submit the following information to the AFRH
prior to your scheduled report date: Submit Later
Covid-19 Test and Vaccine Record (if received): All applicants must test negative for Covid-19 and follow all guidelines
prior to admission. Specific instructions will be included with the Admissions Agreement.
Voided Check for Electronic Funds Transfer (EFT) of Monthly Resident Fee (EFT is required for fee payment)
Current Last Will and Testament
Durable Power of Attorney (POA) for Healthcare
Living Will/Advance Directive
Durable Power of Attorney (POA) for Finance
Pre-Paid Funeral Arrangements
Emergency Contacts, Next of Kin, Executor & Powers of Attorney: Full names, addresses, phone numbers, emails, etc.
Medical Records for the last 12 months (digital format is accepted). Notify us in advance if you receive oxygen therapy.
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 or Gulfport, MS: https://www.dhs.gov/real-id/mississippi
CONTACTS FOR FINANCIAL DOCUMENTS FOR AFRH BUSINESS CENTER
REQUIRED DOCUMENTS
DESCRIPTION
HOW TO OBTAIN IF MISSING
MIL
DD214
MILITARY RECORDS
DD214, NGB22, NERP, ETC.
NATIONAL PERSONNEL RECORDS CENTER
1 Archives Dr., St. Louis, MO 63138
NPRC Toll Free: 1-866-272-6272
www.va.gov/records/get-military-service-records
INCOME
TAXES
1040
Filed Tax Return or Transcript (non-filing)
(Tax Prep help is available at AFRH)
IRS: 1-800-829-1040
or at: www.irs.gov/individuals/get-transcript
Any 1099’s
Social Security, Interest, All sources of
Retirement Income including DFAS
Contact the Issuer:
Social Security:
1-800-772-1213
DFAS:
1-888-332-7411
PenFed:
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 or
www.va.gov/records/download-va-letters/
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
DEDUCTIONS
MEDICAL
Medicare Part A
Hospital Insurance: Most individuals receive Part A
at age 65 (after paying 10 years of Medicare Taxes)
Contact for more information:
1-800-633-4227 (1-800-MEDICARE)
Medicare Part B
Medical Insurance: Must enroll at age 65 (premium-
based) Cost 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 Healthcare or
Dental Insurance
(provide 3 consecutive monthly bank statements)
Contact your bank or other Financial Institution
Supplemental Health
Insurance
If 100% service-connected 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
Addendum | Checklist
Prior Versions No Longer Valid
APP 03-2021
Clear List
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