source: FOIAVistA/trunk/r/ENROLLMENT_APPLICATION_SYSTEM-EAS/EASEZPF2.m@ 1713

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1EASEZPF2 ;ALB/SCK - Print 1010EZ Enrollment Form Cont., Page 2 ; 10/19/2000
2 ;;1.0;ENROLLMENT APPLICATION SYSTEM;;Mar 15, 2001
3 ;
4EN(EALNE,EAINFO) ; Main entry point
5 ; Input
6 ; EALNE - Array of line formats for output
7 ; EAINFO - Application Data array, see SETUP^EASEZPF
8 ;
9 N EASD
10 ;
11 D HDR^EASEZPF(.EALNE,.EAINFO)
12 W !,?50,"SECTION II - FINANCIAL ASSESSMENT",!,EALNE("DD")
13 ;
14 S EASD="^TMP(""EASEZ"",$J,2)"
15 ;
16 D DEP
17 D FIN
18 D INC
19 D EXP
20 D NET
21 ;
22 D FT^EASEZPF(.EALNE,.EAINFO)
23 Q
24 ;
25DEP ; Print out VA 10-10EZ Section IIA, Dependent Information
26 W !,?52,"IIA - DEPENDENT INFORMATION",!,EALNE("D")
27 W !,"1. Spouse's Name ",@EASD@(1),?65,"|2. Child's Name ",@EASD@(2)
28 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
29 ;
30 W !,"3. Spouse's Social Security Number ",$P(@EASD@(3),U),?50,"|4. Spouse's Date Of Birth ",@EASD@(4),?90,"|5. Child's Date Of Birth ",@EASD@(5)
31 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
32 ;
33 W !,"6. Spouse's Address",?65,"|7. Child's Social Security Number"
34 W !?1,$P(@EASD@(6),U),?65,"| ",@EASD@(7)
35 W !?1,$P(@EASD@(6),U,2),?65,"|"
36 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
37 ;
38 W !,"8. Spouse's Telephone Number ",@EASD@(8),?65,"|9. Child's Relationship To You ",@EASD@(9)
39 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
40 ;
41 W !,"10. Date of Marriage ",@EASD@(10),?65,"|11. Date Child Became Your Dependent ",@EASD@(11)
42 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
43 ;
44 W !,"12. If Your Spouse or Dependent Child Did Not Live With You Last",?65,"|13. Expenses Paid By YOUR Dependent Child for College, Vocational"
45 W !,"Year, Enter the Amount you Contributed To Their Support",?65,"|Rehabilitation or Training (tuition, books, materials, etc.)"
46 ;
47 W !?4,"Spouse $ ",$P(@EASD@(12),U),?26,"Child $ ",$P(@EASD@(12),U,2),?65,"| $ ",@EASD@(13)
48 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
49 ;
50 W !,"14. Was Child Permanently And Totally Disabled Before",?65,"|15. If Child is Between 18 and 23 Years Of Age, Did Child"
51 W !,"The Age Of 18? ",@EASD@(14),?65,"| Attend School Last Calendar Year? ",@EASD@(15)
52 Q
53 ;
54FIN ; Print out VA 10-10EZ Section IIB, Financial Disclosure information
55 W !,EALNE("DD")
56 W !,?50,"IIB - FINANCIAL DISCLOSURE"
57 W !,"You are not required to provide the financial information in this Section. However, current law may require VA to consider your"
58 W !,"household financial situation to determine your eligibility for enrollment and/or cost-free care of your nonservice-connected"
59 W !,"(NSC) conditions. If you are 0% SC noncompensable or NSC (and are not an Ex-POW, WWI veteran or VA pensioner) and your"
60 W !,"annual household income (or combined income net worth) exceeds the established threshold, you must agree to pay VA co-payments"
61 W !,"for care of your NSC conditions to be eligible for enrollment. See Section III - Consent and Signature"
62 ;
63 S (EAY,EAN)="___"
64 S:EAINFO("DISC")="YES" EAY=" X "
65 S:EAINFO("DISC")="NO" EAN=" X "
66 ;
67 W !!?4,EAY," YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO HAVE ELIGIBILITY FOR CARE DETERMINED. Complete all"
68 W !?8,"sections below that apply to you with last calendar year's information. Sign and date the application."
69 W !?4,EAN," NO, I DO NOT WISH TO PROVIDE MY DETAILED FINANCIAL INFORMATION. I understand I will be assigned the appropriate enrollment"
70 W !?8,"priority based on nondisclosure of my financial information. By checking NO and signing below, I am agreeing to pay the"
71 W !?8,"applicable VA co-payment. Sign and date the application."
72 Q
73 ;
74INC ; Print out VA 10-10EZ Section IIC, Gross Annual Income information
75 W !,EALNE("DD")
76 W !?17,"IIC - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN"
77 ;
78 W !?73,"| VETERAN",?90,"| SPOUSE",?110,"| CHILDREN"
79 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
80 ;
81 W !,"1. What Was Your Gross Annual Income From Employment (wages, bonuses,"
82 W !,"tips, etc), As Well as Income From Your Farm, Ranch, Property or Business",?73,"| $ "
83 W $P(@EASD@("2C1"),U),?90,"| $ ",$P(@EASD@("2C1"),U,2),?110,"| $ ",$P(@EASD@("2C1"),U,3)
84 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
85 ;
86 W !,"2. List Other Income Amounts (Social Security, compensation, pension,"
87 W !,"interest, dividends) Exclude Welfare.",?73,"| $ "
88 W $P(@EASD@("2C2"),U),?90,"| $ ",$P(@EASD@("2C2"),U,2),?110,"| $ ",$P(@EASD@("2C2"),U,3)
89 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
90 ;
91 W !,"3. Was Income From Your Farm, Ranch, Property or Business (if yes, refer to page 2, Section IIC of the instructions.) ",@EASD@("2C3")
92 ;
93 Q
94 ;
95EXP ; Print out VA 10-10EZ Section IID, Deductible Expense Information
96 W !,EALNE("DD")
97 W !?50,"IID - DEDUCTIBLE EXPENSES"
98 W !,"1. Non-Reimbursed Medical Expenses Paid By You or Your Spouse (payments for doctors, dentists, drugs,"
99 W !,"Medicare, health insurance, hospital and nursing home)",?110,"| $ ",@EASD@("2D1")
100 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
101 ;
102 W !,"2. Amount You Paid Last Calendar Year For Funeral And Burial Expenses For Deceased Spouse or Dependent"
103 W !,"Child (also enter spouse or child's information in Section IIA)",?110,"| $ ",@EASD@("2D2")
104 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
105 ;
106 W !,"3. Amount You Paid Last Calendar Year For YOUR College or Vocational Educational Expenses (tutition, books,"
107 W !,"fees, materials, etc.) Do Not List Your Dependent's Educational Expenses.",?110,"| $ ",@EASD@("2D3")
108 ;
109 Q
110NET ; Print out VA 10-10EZ Section IIE, Net Worth Information
111 W !,EALNE("DD")
112 W !?50,"IIE - NET WORTH"
113 W !?91,"| VETERAN",?110,"| SPOUSE"
114 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
115 ;
116 W !,"1. Cash, Amount In Bank Accounts (checking and savings accounts, certificates of deposit,"
117 W !,"individual retirement accounts, etc.)",?91,"| $ ",$P(@EASD@("2E1"),U),?110,"| $ ",$P(@EASD@("2E1"),U,2)
118 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
119 ;
120 W !,"2. Market Value Of Land And Buildings MINUS Mortgages And Liens. Do NOT COUNT YOUR"
121 W !,"PRIMARY HOME. Include value of farm, ranch, or business assets.",?91,"| $ ",$P(@EASD@("2E2"),U),?110,"| $ ",$P(@EASD@("2E2"),U,2)
122 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
123 ;
124 W !,"3. Stocks And Bonds AND Value Of Other Property or Assets (art, rare coins, etc.) MINUS"
125 W !,"The Amount You Owe On These Items. Exclude household effects and family vehicles.",?91,"| $ ",$P(@EASD@("2E3"),U),?110,"| $ ",$P(@EASD@("2E3"),U,2)
126 Q
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