Va Form 10-10ez - Application For Health Benefits - Department Of Veteran Affairs (Page 3 of 6) in pdf

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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 payment; 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

program.

Section VIII - 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 expenses of last illness and burial expenses, e.g., prepaid burial, paid by the veteran for spouse or

dependent(s).

Section IX - Previous Calendar Net Worth.

Your net worth is the market value of all the interest and rights you have in any kind of property. However net worth does not

include your single-family residence and a reasonable lot area surrounding it. It also does not include the personal things you use

every day like your vehicle, clothing and furniture.

Submitting your application.

Read Section X, Paperwork Reduction and Privacy Act Information , Section XI Consent to Copays and Section XII, Assignment

of Benefits.

In Section XII, 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.

Where do I send my application?

Mail the original application and supporting materials to your local VA health care facility. You can find the address by calling

VA at 1-877-222-VETS (8387), or on the Internet at

10-10EZ

VA FORM

FEB 2011

Va Form 10-10ez - Application For Health Benefits - Department Of Veteran Affairs Page 3