Va Form 10-10hs - Request For Hardship Determination printable pdf download

OMB Approved No. 2900-0091

Estimated Burden Avg. 15 min.

Request for Hardship Determination

The Request for Hardship Determination form is used to determine whether the veteran's projected income for the current year will be

substantially below the VA means test threshold due to a loss of income or increase in allowable deductible expenses. Veterans

determined to have a financial hardship will be exempt from payment of hospital and medical care copays and qualify for enrollment in

Priority Group 5, unless otherwise eligible for enrollment in a higher priority, from the date of request through the last day of the same

calendar year.

GENERAL INFORMATION

(Last, First, Middle Name)

1. VETERAN'S NAME

2. SOCIAL SECURITY NUMBER

(9 digits)

3A. CITY

3B. STATE

3C. ZIP CODE

(Street)

3. PERMANENT ADDRESS

3D. COUNTY

(Include area code)

3F. CELLULAR TELEPHONE NUMBER

(Include area code)

3E. HOME TELEPHONE NUMBER

REASON/CIRCUMSTANCE FOR HARDSHIP REQUEST (Check all that apply and add explanation as needed below)

Increase in number of dependents

Reduction of household income

Paid out of pocket medical expenses

Other - explain below

Moved to a higher cost of living area

Provide explanation, as needed, and attach documentation supporting your request.

PROJECTED HOUSEHOLD INCOME, DEDUCTIBLE EXPENSES & NET WORTH FOR THE CURRENT CALENDAR YEAR

Veteran

Spouse

Children

1. HOUSEHOLD INCOME (Includes gross income from employment,

net income from farm or ranch, and other income amounts.)

2. DEDUCTIBLE EXPENSES (Includes non-reimbursed medical

expenses paid by you or your spouse, funeral and burial expenses

and expenses for the veteran's education.)

3. NET WORTH (Includes cash in banks, market value of lands and

buildings minus mortgages and liens.)

PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION

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

15 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 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.

SIGNATURE AND DATE

I cerifty that the statements on this form are true and correct to the best of my knowledge and belief. By signing this form, I agree that

VA may attempt to verify this information by computer matching agreement with other federal agencies.

VETERAN'S SIGNATURE

DATE

PENALTY: The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any

statement or evidence of a material fact, knowing it to be false.

VA FORM

10-10HS

PAGE 1

OCT 2008

Va Form 10-10hs - Request For Hardship Determination

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