Form 10-302 IRS-SSA Spouse Reported Income

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

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.
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 20 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 10-302 to this email address.

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

3. INCOME YEAR (YYYY)

2. CASE NUMBER

4. SPOUSE'S NAME (Last, First, Middle Name)

OPTION 1

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

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.

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 canceled 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 canceled 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
XXX 2025

10-302

6. DATE SIGNED

(MM/DD/YYYY)

HEC

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