Income Verification

Health Eligibility Center (HEC) Income Verification (IV) Forms

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Income Verification

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HEC Income Verification – Additional Information Checklist


____ Select only one Option, sign and date the HEC Form 200-1A, Income Verification Response.


____ Spouse’s signature and date on the HEC Form 220-1, Spouse Reported Income Verification.


____ Complete, sign, and date the enclosed Declaration of Representative form or provide a

Power of Attorney.


____ Spouse’s Social Security Number, Date of Birth, Date of Marriage.


____ Dependent’s name, Social Security Number, Date of Birth and date become dependent.


____ Copy of signed and dated 2003 U.S. Individual Income Tax Return with all

attachments/schedules.


____ Copy of W-2 Wages/Earning Statement for income year (_ _ _ _) (Veteran, Dependent, or

Spouse).


____ Copy of Divorce Decree or Legal Separation Papers.


____ Copy of paid receipts for out-of-pocket medical expenses for Veteran and family members

for income year (_ _ _ _).


____ Copy of Account Statements that show IRA was rolled over.


____ Copy of paid receipts for funeral/burial expenses for immediate family member(s).


____ Copy of paid receipts for Veteran’s tuition, fees, and book expenses for college or

vocational training.


____ Copy of Form SSA-1099, Social Security Benefit Statement for income year (_ _ _ _)

(Veteran, Dependent, or Spouse). Call toll free 1-800-772-1213 to obtain a form if you do

not have your copy.


____ Check the box on HEC Form 200-1A, Income Verification Response, attesting the real

estate sales was your primary residence for income year (_ _ _ _), if applicable.


Other: _______________________________________________________________________

HEC Form 220-1 (MMM YYYY) Page 2 of 1

File Typeapplication/msword
AuthorVHAIVMDucloB
Last Modified ByMixon, Joni
File Modified2016-06-02
File Created2016-06-02

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