Form 10-301 IRS-SSA Veteran Reported Income

OMB Control Number: 2900-0867
Estimated Burden: 30 minutes
Expiration Date: XX/XX/20XX

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.
VA BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The OMB control number for this project is 2900-0867, and it expires XX/XX/20XX. Public reporting burden for this collection of information
is estimated to average 30 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of
information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-0867 in any
correspondence. Do not send your completed VA Form 10-301 to this email address.

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

3. INCOME YEAR (YYYY)

2. CASE NUMBER

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

I agree my reported total gross household income is
above the VA National Income
Threshold of
. I do not wish to submit documentation of allowable deductible expenses
that may reduce my income below the threshold.

OPTION 2: AGREE/PROVIDING EVIDENCE OF
DEDUCTIBLE EXPENSES

I 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, eyeglasses, hearing aids, funeral/burial
expenses, and educational expenses for the Veteran only.

OPTION 3: DISAGREE

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
XXX 2025

10-301

DOCUMENT TYPE

TYPE OF INCOME

AMOUNT (In US Dollars)

5. DATE SIGNED

(MM/DD/YYYY)

HEC

PAGE 1