| [613] | 1 | EASEZPF2 ;ALB/SCK - Print 1010EZ Enrollment Form Cont., Page 2 ; 10/19/2000
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| 2 | ;;1.0;ENROLLMENT APPLICATION SYSTEM;;Mar 15, 2001
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| 3 | ;
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| 4 | EN(EALNE,EAINFO) ; Main entry point
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| 5 | ; Input
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| 6 | ; EALNE - Array of line formats for output
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| 7 | ; EAINFO - Application Data array, see SETUP^EASEZPF
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| 8 | ;
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| 9 | N EASD
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| 10 | ;
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| 11 | D HDR^EASEZPF(.EALNE,.EAINFO)
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| 12 | W !,?50,"SECTION II - FINANCIAL ASSESSMENT",!,EALNE("DD")
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| 13 | ;
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| 14 | S EASD="^TMP(""EASEZ"",$J,2)"
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| 15 | ;
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| 16 | D DEP
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| 17 | D FIN
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| 18 | D INC
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| 19 | D EXP
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| 20 | D NET
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| 21 | ;
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| 22 | D FT^EASEZPF(.EALNE,.EAINFO)
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| 23 | Q
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| 24 | ;
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| 25 | DEP ; Print out VA 10-10EZ Section IIA, Dependent Information
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| 26 | W !,?52,"IIA - DEPENDENT INFORMATION",!,EALNE("D")
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| 27 | W !,"1. Spouse's Name ",@EASD@(1),?65,"|2. Child's Name ",@EASD@(2)
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| 28 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 29 | ;
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| 30 | W !,"3. Spouse's Social Security Number ",$P(@EASD@(3),U),?50,"|4. Spouse's Date Of Birth ",@EASD@(4),?90,"|5. Child's Date Of Birth ",@EASD@(5)
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| 31 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 32 | ;
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| 33 | W !,"6. Spouse's Address",?65,"|7. Child's Social Security Number"
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| 34 | W !?1,$P(@EASD@(6),U),?65,"| ",@EASD@(7)
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| 35 | W !?1,$P(@EASD@(6),U,2),?65,"|"
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| 36 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 37 | ;
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| 38 | W !,"8. Spouse's Telephone Number ",@EASD@(8),?65,"|9. Child's Relationship To You ",@EASD@(9)
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| 39 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 40 | ;
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| 41 | W !,"10. Date of Marriage ",@EASD@(10),?65,"|11. Date Child Became Your Dependent ",@EASD@(11)
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| 42 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 43 | ;
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| 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"
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| 45 | W !,"Year, Enter the Amount you Contributed To Their Support",?65,"|Rehabilitation or Training (tuition, books, materials, etc.)"
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| 46 | ;
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| 47 | W !?4,"Spouse $ ",$P(@EASD@(12),U),?26,"Child $ ",$P(@EASD@(12),U,2),?65,"| $ ",@EASD@(13)
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| 48 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 49 | ;
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| 50 | W !,"14. Was Child Permanently And Totally Disabled Before",?65,"|15. If Child is Between 18 and 23 Years Of Age, Did Child"
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| 51 | W !,"The Age Of 18? ",@EASD@(14),?65,"| Attend School Last Calendar Year? ",@EASD@(15)
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| 52 | Q
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| 53 | ;
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| 54 | FIN ; Print out VA 10-10EZ Section IIB, Financial Disclosure information
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| 55 | W !,EALNE("DD")
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| 56 | W !,?50,"IIB - FINANCIAL DISCLOSURE"
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| 57 | W !,"You are not required to provide the financial information in this Section. However, current law may require VA to consider your"
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| 58 | W !,"household financial situation to determine your eligibility for enrollment and/or cost-free care of your nonservice-connected"
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| 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"
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| 60 | W !,"annual household income (or combined income net worth) exceeds the established threshold, you must agree to pay VA co-payments"
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| 61 | W !,"for care of your NSC conditions to be eligible for enrollment. See Section III - Consent and Signature"
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| 62 | ;
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| 63 | S (EAY,EAN)="___"
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| 64 | S:EAINFO("DISC")="YES" EAY=" X "
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| 65 | S:EAINFO("DISC")="NO" EAN=" X "
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| 66 | ;
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| 67 | W !!?4,EAY," YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO HAVE ELIGIBILITY FOR CARE DETERMINED. Complete all"
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| 68 | W !?8,"sections below that apply to you with last calendar year's information. Sign and date the application."
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| 69 | W !?4,EAN," NO, I DO NOT WISH TO PROVIDE MY DETAILED FINANCIAL INFORMATION. I understand I will be assigned the appropriate enrollment"
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| 70 | W !?8,"priority based on nondisclosure of my financial information. By checking NO and signing below, I am agreeing to pay the"
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| 71 | W !?8,"applicable VA co-payment. Sign and date the application."
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| 72 | Q
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| 73 | ;
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| 74 | INC ; Print out VA 10-10EZ Section IIC, Gross Annual Income information
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| 75 | W !,EALNE("DD")
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| 76 | W !?17,"IIC - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN"
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| 77 | ;
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| 78 | W !?73,"| VETERAN",?90,"| SPOUSE",?110,"| CHILDREN"
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| 79 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 80 | ;
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| 81 | W !,"1. What Was Your Gross Annual Income From Employment (wages, bonuses,"
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| 82 | W !,"tips, etc), As Well as Income From Your Farm, Ranch, Property or Business",?73,"| $ "
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| 83 | W $P(@EASD@("2C1"),U),?90,"| $ ",$P(@EASD@("2C1"),U,2),?110,"| $ ",$P(@EASD@("2C1"),U,3)
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| 84 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 85 | ;
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| 86 | W !,"2. List Other Income Amounts (Social Security, compensation, pension,"
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| 87 | W !,"interest, dividends) Exclude Welfare.",?73,"| $ "
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| 88 | W $P(@EASD@("2C2"),U),?90,"| $ ",$P(@EASD@("2C2"),U,2),?110,"| $ ",$P(@EASD@("2C2"),U,3)
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| 89 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 90 | ;
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| 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")
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| 92 | ;
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| 93 | Q
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| 94 | ;
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| 95 | EXP ; Print out VA 10-10EZ Section IID, Deductible Expense Information
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| 96 | W !,EALNE("DD")
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| 97 | W !?50,"IID - DEDUCTIBLE EXPENSES"
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| 98 | W !,"1. Non-Reimbursed Medical Expenses Paid By You or Your Spouse (payments for doctors, dentists, drugs,"
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| 99 | W !,"Medicare, health insurance, hospital and nursing home)",?110,"| $ ",@EASD@("2D1")
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| 100 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 101 | ;
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| 102 | W !,"2. Amount You Paid Last Calendar Year For Funeral And Burial Expenses For Deceased Spouse or Dependent"
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| 103 | W !,"Child (also enter spouse or child's information in Section IIA)",?110,"| $ ",@EASD@("2D2")
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| 104 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 105 | ;
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| 106 | W !,"3. Amount You Paid Last Calendar Year For YOUR College or Vocational Educational Expenses (tutition, books,"
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| 107 | W !,"fees, materials, etc.) Do Not List Your Dependent's Educational Expenses.",?110,"| $ ",@EASD@("2D3")
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| 108 | ;
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| 109 | Q
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| 110 | NET ; Print out VA 10-10EZ Section IIE, Net Worth Information
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| 111 | W !,EALNE("DD")
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| 112 | W !?50,"IIE - NET WORTH"
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| 113 | W !?91,"| VETERAN",?110,"| SPOUSE"
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| 114 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 115 | ;
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| 116 | W !,"1. Cash, Amount In Bank Accounts (checking and savings accounts, certificates of deposit,"
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| 117 | W !,"individual retirement accounts, etc.)",?91,"| $ ",$P(@EASD@("2E1"),U),?110,"| $ ",$P(@EASD@("2E1"),U,2)
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| 118 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 119 | ;
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| 120 | W !,"2. Market Value Of Land And Buildings MINUS Mortgages And Liens. Do NOT COUNT YOUR"
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| 121 | W !,"PRIMARY HOME. Include value of farm, ranch, or business assets.",?91,"| $ ",$P(@EASD@("2E2"),U),?110,"| $ ",$P(@EASD@("2E2"),U,2)
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| 122 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 123 | ;
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| 124 | W !,"3. Stocks And Bonds AND Value Of Other Property or Assets (art, rare coins, etc.) MINUS"
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| 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)
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| 126 | Q
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