Form Dma-5027 - North Carolina Department Of Social Services
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1From:
County Department of Social Services, North Carolina
To:
US Department of Veterans Affairs (USDVA)
Date: __________________
Fax No. 215-381-3191
Attn: Gary Hodge
We are determining eligibility for public assistance. Please verify the amount of the VA
benefits the claimant is receiving or entitled to and return this form by fax to worker
listed below.
VA Claimant Name: ___________________ Veteran’s Name (if different): ___________________
VA Claim Number:
_ Claimant Social Security #:
____
I hereby grant permission and authorize the U.S. Dept. of Veterans Affairs to disclose to
the above county department of social Services information that will be solely used for
determining eligibility for Medicaid. _________________________________
__________
Signature of claimant
date
If you (USDVA) have questions about completing this verification form, please contact
worker ________________________________ at:
Phone: _______________ Fax:
_______________
Information to be completed by Department of Veterans Affairs:
VA Claim Number (if not supplied above) _____________________________________________
Benefit Type:
[ ] Old Pension Law (Protected Pension Program)
[ ] Improved Pension
[ ] Reduced Improved Pension (up to $90 payment)[P.L. 102-568]
[ ] Compensation
[ ] Apportionment
[ ] Other
TOTAL VA Gross Monthly Benefit Amount: $
effective
.
Does it include?
[ ] Aid & Attendance (A&A)
Amount:
$_________________
[ ] Homebound/Housebound (HB)
Amount:
$
[ ]
Educational Benef
its
Amount:
$_________________
[ ] None of the above
Unusual Medical Expenses (UME)
Is VA benefit for this individual based on continued unreimbursed Unusual
Medical Expenses [ ]Yes
[ ]No
Amount of benefit received due to UME $_________________
Has claimant received any lump sum payments?
[ ] Yes
[ ] No
If yes, is lump sum for [ ] Retroactive Benefits [ ] Unusual Medical Expenses
Date received
and amount
Verified by:
___________ Phone Number: ______________________
Title:
Date:
For County DSS Use Only
ABD
F&C
Gross Benefit Amount
____________
Gross Benefit Amount
___________
Minus A&A/Homebound/Housebound amount____________
Minus educational benefit ___________
Equals countable benefit
___________
Minus amount received due to UME
____________
Minus educational benefit
____________
Equals countable benefit amount
____________
DMA-5027 (Revised 12/12)
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