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1EASEC10R ;ALB/LBD - Print 1010EC LTC Enrollment form ; 9/20/01 12:25pm
2 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**40**;Mar 15, 2001
3 ;
4 ; Called from ^EASEC10E to print pages 2 and 3 of the revised 1010EC
5 ;
6PAGE2(EALNE,EAINFO,EASDFN) ;Print page 2 of revised 1010EC
7 N X,EASROOT
8 S EASROOT="^TMP(""1010EC"",$J,"_EASDFN_","
9 D HDR^EASEC10E(.EALNE,.EAINFO)
10 D SIGN
11 D SEC4
12 D SEC5 ;SEC 6 is part of SEC 5
13 D SEC7
14 D FT^EASEC10E(.EALNE,.EAINFO)
15 Q
16SIGN ;print disclaimer and signature block to refuse income data
17 ;
18 W !,"I do not wish to provide my detailed financial information. "
19 W "I understand that I will be assessed the maximum copayment amount for"
20 W !,"extended care services and agree to pay the applicable VA copayment as required by law.",?131,$C(13) X EAINFO("L")
21 W !,"Signature",?97,"| Date",!?97,"|",?131,$C(13) X EAINFO("L")
22 Q
23 ;
24SEC4 ; print section 4 - Fixed Assets (Veteran and Spouse)
25 N EAS4
26 S EAS4=EASROOT_"4)"
27 W !?23,"SECTION IV - FIXED ASSETS (VETERAN AND SPOUSE)",?97,"|",?102,"VETERAN",?113,"|",?119,"SPOUSE",?131,$C(13) X EAINFO("L")
28 ;
29 W !,"1. Primary Residence (Market value minus mortgages or liens. "
30 W "Exclude if veteran receiving only",?97,"| $",$J(@EAS4@(1),12,2),?113,"| $",$J(@EAS4@(1.5),12,2)
31 W !?3,"non-institutional extended care services or spouse or dependent residing in community. If the",?97,"|",?113,"|"
32 W !?3,"veteran and spouse maintain separate residences, and the veteran is receiving institutional",?97,"|",?113,"|"
33 W !?3,"(inpatient) extended care services, include value of the veteran's primary residence.)",?97,"|",?113,"|",?131,$C(13) X EAINFO("L")
34 ;
35 W !,"2. Other Residences/Land/Farm or Ranch (Market value minus mortgages or liens. "
36 W "This would",?97,"| $",$J(@EAS4@(2),12,2),?113,"| $",$J(@EAS4@(2.5),12,2)
37 W !?3,"include a second home, vacation home, rental property.)",?97,"|",?113,"|",?131,$C(13) X EAINFO("L")
38 ;
39 W !,"3. Vehicle(s) (Value minus outstanding lien. Exclude primary vehicle if veteran "
40 W "receiving only",?97,"| $",$J(@EAS4@(3),12,2),?113,"| $",$J(@EAS4@(3.5),12,2)
41 W !?3,"non-institutional extended care services or spouse or dependent residing in community. If the",?97,"|",?113,"|"
42 W !?3,"veteran and spouse maintain separate residences and vehicles, and the veteran is receiving",?97,"|",?113,"|"
43 W !?3,"institutional (inpatient) extended care services, include value of veteran's primary vehicle.)",?97,"|",?113,"|",?131,$C(13) X EAINFO("L")
44 ;
45 Q
46SEC5 ; print section 5 - Liquid Assets (Veteran and Spouse)
47 N EAS5
48 S EAS5=EASROOT_"5)"
49 W !?23,"SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE)",?97,"|",?113,"|",?131 X EAINFO("L")
50 ;
51 W !,"1. Cash, Amount in Bank Accounts (e.g., checking and savings accounts, certificates "
52 W "of deposit",?97,"| $",$J(@EAS5@(1),12,2),?113,"| $",$J(@EAS5@(1.5),12,2)
53 W !?3,"individual retirement accounts, stocks and bonds.)"
54 W ?97,"|",?113,"|",?131,$C(13) X EAINFO("L")
55 ;
56 W !,"2. Value of Other Liquid Assets (e.g., art, rare coins, stamp collections, collectibles) Minus"
57 W ?97,"| $",$J(@EAS5@(3),12,2),?113,"| $",$J(@EAS5@(3.5),12,2)
58 W !?3,"the amount you owe on these items. Exclude household effects, clothing, jewelry, and personal",?97,"|",?113,"|"
59 W !?3,"items if veteran receiving only non-institutional extended care services or spouse or",?97,"|",?113,"|"
60 W !?3,"dependent residing in the community.",?97,"|",?113,"|",?131,$C(13) X EAINFO("L")
61 ;
62 W !," SUM OF ALL LINES FIXED AND LIQUID ASSETS"
63 W ?75,"| TOTAL ASSETS",?97,"| $",$J(@EAS5@(5),12,2),?113,"| $",$J(@EAS5@(5.5),12,2),?131,$C(13) X EAINFO("L")
64 ;
65 ; print section 6 - Current Gross Income
66 W !?23,"SECTION VI - CURRENT GROSS INCOME OF VETERAN AND SPOUSE",?97,"|",?113,"|",?131 X EAINFO("L")
67 W !?45,"CATEGORY",?97,"|",?102,"VETERAN",?113,"|",?119,"SPOUSE",?131,$C(13) X EAINFO("L")
68 ;
69 W !,"1. Gross annual income from employment (e.g., wages, bonuses, tips, severance pay"
70 W ?97,"| $",$J(@EAS5@(6),10,2),?113,"| $",$J(@EAS5@(7),10,2)
71 W !,"accrued benefits)",?97,"|",?113,"|",?131,$C(13) X EAINFO("L")
72 ;
73 W !,"2. Net income from your farm/ranch, property or business.",?97,"| $",$J(@EAS5@(10),10,2),?113,"| $",$J(@EAS5@(11),10,2),?131,$C(13) X EAINFO("L")
74 ;
75 W !,"3. List other income amounts (e.g., Social Security, retirement and pension, ",?97,"| $",$J(@EAS5@(32),10,2),?113,"| $",$J(@EAS5@(33),10,2)
76 W !?3,"interest, dividends) Refer to instructions.",?97,"|",?113,"|",?131,$C(13) X EAINFO("L")
77 Q
78SEC7 ; print section 7 - Expenses
79 ; Expenses are in section 7 on the new 10-10EC (section 6 on the old)
80 N EAS6
81 S EAS6=EASROOT_"6)"
82 ;
83 W !?43,"SECTION VII - DEDUCTIBLE EXPENSES",!,EALNE("D")
84 W !?54,"ITEMS",?113,"|",?119,"AMOUNT",?131,$C(13) X EAINFO("L")
85 W !,"1. Educational expenses of veteran, spouse or dependent (e.g., tuition, books, fees, material, etc.)",?113,"| $",$J(@EAS6@(1),10,2),?131,$C(13) X EAINFO("L")
86 W !,"2. Funeral and Burial (spouse or child, amount you paid for funeral and burial expenses, including prepaid",?113,"| $",$J(@EAS6@(2),10,2)
87 W !?3,"arrangements)",?113,"|",?131,$C(13) X EAINFO("L")
88 W !,"3. Rent/Mortgage (monthly amount or annual amount)",?113,"| $",$J(@EAS6@(3),10,2),?131,$C(13) X EAINFO("L")
89 W !,"4. Utilities (calculate by average monthly amounts over the past 12 months)",?113,"| $",$J(@EAS6@(4),10,2),?131,$C(13) X EAINFO("L")
90 W !,"5. Car Payment for one vehicle only (exclude gas, automobile insurance, parking fees, repairs)",?113,"| $",$J(@EAS6@(5),10,2),?131,$C(13) X EAINFO("L")
91 W !,"6. Food (for veteran, spouse and dependent)",?113,"| $",$J(@EAS6@(6),10,2),?131,$C(13) X EAINFO("L")
92 W !,"7. Non-reimbursed medical expenses paid by you or spouse (e.g., copayments for physicians, dentists,",?113,"| $",$J(@EAS6@(7),10,2)
93 W !?3,"medications, Medicare, health insurance, hospital and nursing home expenses)",?113,"|",?131,$C(13) X EAINFO("L")
94 W !,"8. Court-ordered payments (e.g., alimony, child support)",?113,"| $",$J(@EAS6@(8),10,2),?131,$C(13) X EAINFO("L")
95 W !,"9. Insurance (e.g., automobile insurance, homeowners insurance) Exclude life insurance",?113,"| $",$J(@EAS6@(9),10,2),?131,$C(13) X EAINFO("L")
96 W !,"10. Taxes (e.g., personal property for home, automobile) Include average monthly expense for taxes paid on",?113,"| $",$J(@EAS6@(10),10,2)
97 W !?3,"income over the past 12 months.",?113,"|",?131,$C(13) X EAINFO("L")
98 W !,?95,"| TOTAL",?113,"| $",$J(@EAS6@(11),10,2),?131
99 Q
100 ;
101PAGE3(EALNE,EAINFO,EASDFN) ;Print page 3
102 N X,EASROOT
103 S EASROOT="^TMP(""1010EC"",$J,"_EASDFN_","
104 D HDR^EASEC10E(.EALNE,.EAINFO)
105 D SEC8
106 D SEC9
107 D SEC10
108 D FT^EASEC10E(.EALNE,.EAINFO)
109 Q
110 ;
111SEC8 ; print section 8 - Consent for Assignment of Benefits
112 ; (section 7 on old 10-10EC form)
113 D SEC7^EASEC103
114 Q
115 ;
116SEC9 ;print section 9 - Consent to Agreement to Make Copayments
117 ; (section 8 on old 10-10EC form)
118 D SEC8^EASEC103
119 Q
120 ;
121SEC10 ; print section 10 - Paperwork Privacy Act Information
122 N I,WPLINE,EAS8,WPCNT
123 S EAS8=EASROOT_"8)",WPLINE=0,WPCNT=1
124 W !?43,"SECTION X - PAPERWORK PRIVACY ACT INFORMATION",!,EALNE("D")
125 W !,"The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance"
126 W !,"requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to"
127 W !,"respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all"
128 W !,"individuals who must complete this form will average 90 minutes. This includes the time it will take to read instructions, gather"
129 W !,"the necessary facts and fill out the form. If you have comments regarding this burden estimate or any other aspect of this"
130 W !,"collection, call 202.273.8247 for mailing information on where to send your comments.",!
131 W !,"Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code,"
132 W !,"sections 1710, 1712, 1722 and 1729 in order for VA to determine your eligibility for extended care benefits and to establish"
133 W !,"financial eligibility, if applicable, when placed in extended care services. The information you supply may be verified through a"
134 W !,"computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a"
135 W !,"""routine use"" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the"
136 W !,"VHA Notice of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA will be unable to process"
137 W !,"your request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to"
138 W !,"which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may"
139 W !,"also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other"
140 W !,"purposes authorized or required by law.",?131,$C(13) X EAINFO("L")
141 W !,"Additional Comments:"
142 D:$D(EAS8)
143 .F S WPLINE=$O(@EAS8@(WPLINE)) Q:'WPLINE S WPCNT=WPCNT+1 W !,@EAS8@(WPLINE)
144 F I=WPCNT:1:14 W !
145 Q
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