Addendum | Checklist
Prior Versions No Longer Valid
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)
MILITARY 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.
HEALTH 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)
DENTAL/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
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.
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
) : 3 consecutive bank statements from each year (9 total)
FILED INCOME TAX RETURNS FOR 2019 & 2020 (by APR 15
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
) 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
2020 : SSA Form 1099 – Social Security Benefits
2020 : OPM Form 1099R – Civil Service Retirement / Annuity
2020 : Form 1099R, 1099-INT, 1099-DIV, 1099-MISC, etc.
2020 : Form W-2 Wages, Gambling, Rent, etc.
2020 : Any Other Income Sources (business, profits, investments, alimony, 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)
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