IRS-SSA Veteran Reported Income

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

Documents and Forms

Document Name Document Type
Form 10-301 IRS-SSA Veteran Reported Income Form and Instruction
10-301 IRS-SSA Veteran Reported Income VA Form 10-301_revised draft_2025.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	IRS-SSA Veteran Reported Income	Agency IC Tracking Number:	2900-0867

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-301	IRS-SSA Veteran Reported Income	VA Form 10-301_revised draft_2025.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 55,896	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	55,896	55,896
Annual IC Time Burden (Hours)	27,948	27,948
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.