Va Form 10-10ez - Application For Health Benefits - Department Of Veteran Affairs Page 5
ADVERTISEMENT
1
2
3
4
5
6(Last, First, Middle)
SOCIAL SECURITY NUMBER
VETERAN'S NAME
APPLICATION FOR HEALTH BENEFITS, Continued
SECTION III - EMPLOYMENT INFORMATION
1. VETERAN'S EMPLOYMENT STATUS
1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
heck one)
(C
FULL TIME
NOT EMPLOYED
If employed or retired,
complete item 1A
PART TIME
RETIRED
Date of retirement
(mm/dd/yyyy)
2. SPOUSE'S EMPLOYMENT
2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
(Check one)
STATUS
FULL TIME
NOT EMPLOYED
If employed or retired,
complete item 2A
PART TIME
RETIRED
Date of retirement
(mm/dd/yyyy)
SECTION IV - MILITARY SERVICE INFORMATION
1. LAST BRANCH OF SERVICE
1A. LAST ENTRY DATE
1B. LAST DISCHARGE DATE
1C. DISCHARGE TYPE
1D. MILITARY SERVICE NUMBER
2. CHECK YES OR NO
YES
NO
YES
NO
A. ARE YOU A PURPLE HEART AWARD RECIPIENT?
E. DID YOU SERVE IN SW ASIA DURING THE GULF WAR BETWEEN
AUGUST 2, 1990 AND NOVEMBER 11, 1998?
F. DID YOU SERVE IN VIETNAM BETWEEN JANUARY 9, 1962 AND
B. ARE YOU A FORMER PRISONER OF WAR?
MAY 7, 1975?
C. DID YOU SERVE IN COMBAT AFTER 11/11/1998?
G. WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY?
H. DID YOU RECEIVE NOSE AND THROAT RADIUM TREATMENTS
D. WAS YOUR DISCHARGE FROM MILITARY FOR A DISABILITY INCURRED
WHILE IN THE MILITARY?
OR AGGRAVATED IN THE LINE OF DUTY?
D1. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF
I. DO YOU HAVE A SPINAL CORD INJURY?
VA COMPENSATION?
SECTION V - FINANCIAL DISCLOSURE
Disclosure allows VA to accurately determine whether certain Veterans will be charged copays for care and medications, their
eligibility for other services and enrollment priority. Veterans are not required to disclose their financial information; however, VA is
not currently enrolling new applicants who decline to provide their financial information unless they have other qualifying eligibility
factors. Recent Combat Veterans are eligible for enrollment without disclosing their financial information but like other
Veterans may provide it to establish their eligibility for travel assistance, cost-free medication and/or medical care for services
unrelated to military experience.
No, I do not wish to provide financial information in Sections VI through IX. I understand that VA is not enrolling new
applicants who do not provide this information and who do not have other qualifying eligibility factors [i.e., a former Prisoner of
War; in receipt of a Purple Heart; a recently discharged Combat Veteran (e.g., OEF/OIF/OND who were discharged within the
past 5 years); discharged for a disability incurred or aggravated in the line of duty; receiving VA service-connected disability
compensation; receiving VA pension; or in receipt of Medicaid benefits.] Sign and date the form in Section XII.
Yes, I will provide my household financial information for last calendar year. Complete applicable sections VI through IX.
Sign and date the form in Section XII.
SECTION VI - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
(Last, First, Middle Name)
(Last, First, Middle Name)
1. SPOUSE'S NAME
2. CHILD'S NAME
(Check one)
1A. SPOUSE'S MAIDEN NAME OR OTHER NAMES USED
2A. CHILD'S RELATIONSHIP TO YOU
Son
Daughter
Stepson
Stepdaughter
1B. SPOUSE'S SOCIAL SECURITY NUMBER
2B. CHILD'S SOCIAL SECURITY NUMBER
2C. DATE CHILD BECAME YOUR DEPENDENT
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
1C. SPOUSE'S DATE OF BIRTH
1D. DATE OF MARRIAGE
2D. CHILD'S DATE OF BIRTH
(Street, City, State, ZIP - if different
2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?
1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER
from Veteran's)
YES
NO
2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST
CALENDAR YEAR?
YES
NO
2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL
3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID
(e.g., tuition, books, materials)
YOU PROVIDE SUPPORT?
REHABILITATION OR TRAINING
$
YES
NO
VA FORM
PAGE 2
10-10EZ
FEB 2011
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal