220-1 Spouse - Income Verification Response

Spouse – Income Verification Response
Name of Veteran:	Name of Spouse:	Income Year:	Case Number:

Document Contains Federal Tax Information

End of Reported Federal Tax Information

If you have additional earned or unearned income information for ~IncomeYear~ that is not listed, please write it below.

PAYER NAME	DOCUMENT TYPE	TYPE OF INCOME	AMOUNT

I declare to the best of my knowledge and belief that the income listed above is correct or I have provided supporting documentation of the correct amounts. I understand the Department of Veterans Affairs (VA) will use this information to determine my Veteran spouse’s eligibility for VA health care.

Signature (Required):	Date (Required):
Sign and date this form. Return the form and any copies of your supporting documentation to: VA Health Eligibility Center, Income Verification Division, 2957 Clairmont Road, Atlanta, GA 30329−1647

If you sign with an “X”, two people you know must witness your signature as you sign. They must print their names, sign and date the form below.

___________________________ ____________________________________ _______________

Witness’ Name (Please Print) Signature Date

___________________________ ____________________________________ _______________

Witness’ Name (Please Print) Signature Date

Spouse – Income Verification Response
Name of Veteran:	Name of Spouse:	Income Year:	Case Number:

If you determine that there is an error with any of the ~IncomeYear~ information listed, please

provide a copy of the correct supporting documentation; the following documents may be used:

• W-2 Form(s) from employer(s)

• Form 1099 for any interest, stocks, bonds, dividends, etc., from financial institutions

• End-of-Year statements from financial institutions

Note: If separated or divorced, please provide legal documentation.

For more information about VA health care eligibility and enrollment, visit VA’s website at www.va.gov/healthbenefits.

Privacy Act Information: VA is asking you to provide the information on this form under Title 38, United States Code, sections 1710,1712, and 1722 in order to determine your Veteran spouse's eligibility for medical benefits. The 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 "routine use" disclosure for: civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration. You do not have to provide the information to VA, but if you do not, we will be unable to process your Veteran spouse's request and serve their medical needs. Failure to furnish the information will not have any effect on any other benefits to which your Veteran spouse may be entitled. If you give VA your Social Security Number, VA will use it to administer your Veteran spouse's VA benefits, to identify Veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.

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