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 expenses.
• 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 V - 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
Section VI - Previous Calendar Year Deductible Expenses.
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).
Section VII - 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.
Section IV - Dependent Information: Include the following:
• Your spouse even if you did not live together, as long as you contributed support last calendar year.
• Your biological children, adopted children, and stepchildren who are unmarried and under the age of 18, or at least 18 but under
23 and attending high school, college or vocational school (full or part-time), or became permanently unable to support
themselves before age 18.
• Child support contributions. Contributions can include tuition or clothing payments or payments of medical bills.
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.