Form 10-301 IRS-SSA Veteran Reported Income

OMB Control Number: 2900-0867
Estimated Burden: 30 minutes
Expiration Date: 01/31/2025

IRS/SSA VETERAN REPORTED INCOME
PRIVACY ACT INFORMATION: Title 38, United States Code, Sections 501(a), 1705, 1710, 1722, 5317 and Public Law 101–508, the Omnibus Budget Reconciliation
Act of 1990 grants the Department of Veterans Affairs (VA) the authority to verify Veterans’ self-reported household income to determine eligibility for medical benefits.
The VA also has the authority to verify Veterans’ self-reported income with the Internal Revenue Service (IRS) and Social Security Administration (SSA). With the
exception of Federal Tax Information (FTI), VA may make routine use disclosure under the authority of 45 CFR Parts 160 and 164 which permits such disclosures. The
information being requested is voluntary, however failure to provide the information requested may delay or result in the denial of your health care benefits. Failure to
furnish the information request will however not affect any benefits for which you are already deemed eligible due to service connection.
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 30 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the form.

SECTION I - GENERAL INFORMATION
1. VETERAN'S NAME (Last, First, Middle Name)

2. CASE NUMBER

3. INCOME YEAR (YYYY)

SECTION II - VERIFICATION OF INFORMATION
Please select the option below which best represents your response to our attempt to verify your income information. This will help us determine your copay
responsibilities and eligibility for VA health care benefits. Please understand that your income information is based on your gross household income
(includes income of spouse and dependent children):
OPTION 1: AGREE

OPTION 2: AGREE/PROVIDING
EVIDENCE OF DEDUCTIBLE EXPENSES

OPTION 3: DISAGREE

I agree with the gross household financial information provided by IRS/SSA. I understand I may be
back billed for any unpaid medical copays.
I agree with the financial information provided by IRS/SSA and have enclosed documentation of
allowable deductible expenses that may reduce my income below the threshold. Examples of allowable
deductible expenses are unreimbursed medical expenses, such as prescription drugs, Medicare
premiums, health insurance premiums, lab tests, eye glasses, hearing aids, funeral/burial expenses
and educational expenses for the Veteran only.
I disagree with the financial information provided by IRS/SSA. I have enclosed copies of supporting
documentation for disputed IRS/SSA information. I understand VA may use this information to
determine my eligibility for health care benefits and may obtain verification from financial institutions
and/or employers.

SECTION III - ADDITIONAL INFORMATION
I certify that my sale of real estate was my primary residence.

SECTION IV - FINANCIAL INFORMATION

Gross household income provided by IRS/SSA.
PAYER NAME

4. SIGNATURE OF APPLICANT

VA FORM
SEP 2021

10-301

DOCUMENT TYPE

TYPE OF INCOME

AMOUNT (In US Dollars)

5. DATE SIGNED (MM/DD/YYYY)

HEC

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