Fillable PROOF OF ELIGIBILITY: Submit proof of military eligibility, (Armed Forces Retirement Home)

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PROOF OF ELIGIBILITY: Submit proof of military eligibility, (Armed Forces Retirement Home)

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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Prior Versions No Longer Valid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
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
2019
2019
2019
2019
2019
2019
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
APP 03-2021
Clear List
Addendum | Checklist
Prior Versions No Longer Valid
APP 03-2021
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
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
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:
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
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
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
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
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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PROOF OF ELIGIBILITY: Submit proof of military eligibility, (Armed Forces Retirement Home)

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Completed 21 June 2021

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