Form 10-303 Declaration of Representative

OMB Control Number: 2900-0867
Estimated Burden: 15 minutes
Expiration Date: XX/XX/20XX

DECLARATION OF REPRESENTATIVE
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 15 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 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 10-303 to this email address.

GENERAL INFORMATION

The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this
form is solicited under Title 38 and Title 26 U.S.C. and will authorize release of information you specify. Your disclosure of the information requested
on this form is voluntary. However, if the information is not furnished, Department of Veterans Affairs will be unable to comply with the request.
1. VETERAN'S NAME (Last, First, Middle Name)

2. SOCIAL SECURITY NUMBER

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

4. SPOUSE'S SOCIAL SECURITY NUMBER

5. VETERAN'S ADDRESS (Street, City & Zip Code)

6. VETERAN'S TELEPHONE NUMBER

7. REPRESENTATIVE'S FULL NAME (Last, First, Middle Name)

8. REPRESENTATIVE'S TELEPHONE NUMBER

9. REPRESENTATIVE'S ADDRESS (Street, City & Zip Code)

I hereby appoint the above named organization or individual as my representative and authorize the Department of Veterans Affairs (VA) to release
confidential tax information and other income and medical benefits eligibility related records maintained by the Health Eligibility Center for current
income year. Income Year:
Without my express revocation, this authorization shall remain in full force for this year.
Redisclosure of the aforementioned information or records by my representative other than to VA is not authorized without my further written consent.
I certify that this authorization has been made freely, voluntarily and without coercion
10. VETERAN'S SIGNATURE

11. DATE SIGNED (MM/DD/YYYY)

12. SPOUSE'S SIGNATURE (If applicable)

13. DATE SIGNED (MM/DD/YYYY)

VA FORM
XXX 2025

10-303

HEC

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