Form 10-302a Spouse Additional Income

OMB Control Number: 2900-0867
Estimated Burden: 15 minutes
Expiration Date: 01/31/2025

SPOUSE ADDITIONAL INCOME INFORMATION
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 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 affect 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.
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.

GENERAL INFORMATION
1. CASE NUMBER

If you have additional earned or unearned income information that is not listed, please write it below.
PAYER NAME

DOCUMENT TYPE

TYPE OF INCOME

AMOUNT (In US Dollars)

CERTIFICATION AND CONSENT: I certify the income is correct as I have listed or as 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.
2. SIGNATURE

VA FORM
SEP 2021

10-302a

3. DATE SIGNED (MM/DD/YYYY)

HEC

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