Form 10-302 IRS-SSA Spouse Reported Income

OMB Control Number: 2900-0867
Estimated Burden: 20 minutes
Expiration Date: 01/31/2025

IRS/SSA SPOUSE 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 20 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)

4. SPOUSE'S NAME (Last, First, Middle Name)
If you determine there is an error with any of the income year information listed below, please provide proof of the correct information. The following
documents can be used as evidence of proof:
• 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
Income may be reduced if any of the following documents are provided as evidence for the income year:
• Copies of paid receipts or cancelled checks for out-of-pocket medical expenses (physician, dentist, hospital, nursing home fees, health insurance
premiums including Medicare premiums), prescription drugs and eye care not covered by health insurance
• Copies of paid receipts or cancelled checks for funeral/burial expenses for spouse or dependent child(ren)
• Copies of paid receipts or cancelled checks for Veteran's tuition, fees, and book expenses for post-secondary or vocational training
Note: If separated or divorced, please provide legal documentation.

SECTION II - FINANCIAL INFORMATION
PAYER NAME

DOCUMENT TYPE

TYPE OF INCOME

AMOUNT (In US Dollars)

CERTIFICATION AND CONSENT: I certify the income listed above is correct or I have provided proof 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.
5. SIGNATURE (Required)

VA FORM
SEP 2021

10-302

6. DATE SIGNED (MM/DD/YYYY)

HEC

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