source: internationalization/trunk/TranslationSpreadsheets/WV-DIALOG-0063.txt@ 703

English French  Notes   Complete/Exclude
SUM OF ALL LINES FIXED AND LIQUID ASSETS                        
TOTAL ASSETS                    
Current income, e.g. gross income (including, but not limited                   
to, wages and income from                       
a business, bonuses, tips, severance pay, accrued benefits,                     
cash gifts)                     
Social Security Retirement/Disability                   
Interest/Dividends (i.e., interest income, standard dividend                    
income from non tax deferred                    
Retirement and Pension income                   
Civil Service Retirement                        
US Railroad Retirement                  
VA Pension                      
Spouse VA disability/compensation                       
Unemployment Benefits/Compensation                      
Other compensation, e.g. Workers Compensation and Black Lung                    
Court Mandated (e.g. alimony, child support) (Veteran and Spouse)                       
Other Income (i.e., inheritance amounts, tort settlement                        
SECTION VI - EXPENSES                   
1. Education (veteran, spouse or dependent)                     
2. Funeral and Burial (spouse or child)                 
5. Car Payment Only (excludes gas, insurance, parking fees)                     
7. Non-reimbursed medical expenses                      
8. Court-ordered payments                       
9. Insurance (exclude life insurance)                   
10. Taxes (on any amount include in gross income, property, personal)                   
SECTION                         
 - CONSENT FOR ASSIGNMENT OF BENEFITS                   
I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from my                        
medical records to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of                       
the expense of care or to any other party against whom liability is asserted.  I understand that I may revoke this authorization at                     
any time, except to the extent that action has already been taken in reliance on it.  Without my express revocation, this consent                       
will automatically expire when all action arising from VA's claim for reimbursement from my medical care has been completed.                    
I authorize payment of medical benefits to VA for any services for which payment is accepted.                   
 - CONSENT AND AGREEMENT TO MAKE COPAYMENTS                     
has received a copy of the Privacy Act Statement and agrees to make appropriate copayments.                     
I certify the foregoing statement(s) are true and correct to the best of my knowledge and belief and agree to make the applicable                       
copayment for extended care services as required by law.                        
Additional Comments:                    
This output requires a 132 column printer.                      
1010EC PRINT                    
APPLICATION FOR EXTENDED CARE SERVICES                  
SECTION I - GENERAL INFORMATION                 
APPLICATION FOR EXTENDED CARE SERVICES, Continued                       
| Social Security Number                        
VA FORM 10-10EC DEC                     
1. Primary Residence (Market value minus mortgages or liens.                    
Exclude if veteran receiving only                       
non-institutional extended care services or spouse or dependent residing in community. If the                   
veteran and spouse maintain separate residences, and the veteran is receiving institutional                     
(inpatient) extended care services, include value of the veteran's primary residence.)                  
This would                      
include a second home, vacation home, rental property.)                 
3. Vehicle(s) (Value minus outstanding lien. Exclude primary vehicle if veteran                         
institutional (inpatient) extended care services, include value of veteran's primary vehicle.)                  
1. Cash, Amount in Bank Accounts (e.g., checking and savings accounts, certificates                     
of deposit                      
individual retirement accounts, stocks and bonds.)                      
2. Value of Other Liquid Assets (e.g., art, rare coins, stamp collections, collectibles)  Minus                 
the amount you owe on these items. Exclude household effects, clothing, jewelry, and personal                   
items if veteran receiving only non-institutional extended care services or spouse or                   
dependent residing in the community.                    
 SUM OF ALL LINES FIXED AND LIQUID ASSETS                       
|    TOTAL ASSETS                       
SECTION VI - CURRENT GROSS INCOME OF VETERAN AND SPOUSE                 
1. Gross annual income from employment (e.g., wages, bonuses, tips, severance pay                       
accrued benefits)                       
2. Net income from your farm/ranch, property or business.                       
3. List other income amounts (e.g., Social Security, retirement and pension,                    
interest, dividends)  Refer to instructions.                    
SECTION VII - DEDUCTIBLE EXPENSES                       
1. Educational expenses of veteran, spouse or dependent (e.g., tuition, books, fees, material, etc.)                    
2. Funeral and Burial (spouse or child, amount you paid for funeral and burial expenses, including prepaid                      
3. Rent/Mortgage (monthly amount or annual amount)                      
4. Utilities (calculate by average monthly amounts over the past 12 months)                     
5. Car Payment for one vehicle only (exclude gas, automobile insurance, parking fees, repairs)                  
6. Food (for veteran, spouse and dependent)                     
7. Non-reimbursed medical expenses paid by you or spouse (e.g., copayments for physicians, dentists,                    
medications, Medicare, health insurance, hospital and nursing home expenses)                    
8. Court-ordered payments (e.g., alimony, child support)                        
9. Insurance (e.g., automobile insurance, homeowners insurance) Exclude life insurance                  
10. Taxes (e.g., personal property for home, automobile) Include average monthly expense for taxes paid on                      
income over the past 12 months.                 
SECTION X - PAPERWORK PRIVACY ACT INFORMATION                   
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance                      
requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to                 
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all                      
individuals who must complete this form will average 90 minutes. This includes the time it will take to read instructions, gather                       
the necessary facts and fill out the form. If you have comments regarding this burden estimate or any other aspect of this                      
collection, call 202.273.8247 for mailing information on where to send your comments.                   
Privacy Act Information:  The VA is asking you to provide the information on this form under Title 38, United States Code,                      
sections 1710, 1712, 1722 and 1729 in order for VA to determine your eligibility for extended care benefits and to establish                    
financial eligibility, if applicable, when placed in extended care services. The information you supply may be verified through a                       
computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a                  
routine use                     
 disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the                     
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                       
your request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to                 
which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may                 
also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other                   
purposes authorized or required by law.                 
Patient is not a Veteran.                       
Date of LTC Copay Test:                         
The date of test must be after the date of the last test on                     
An LTC Copay Test already exists on                     
Are you sure you want to add a new test                 
LTC COPAY                       
   Use the 'EASEC                       
TEST EDIT' Option.                      
TEST VIEW' Option.                      
Is veteran EXEMPT from LTC copayments                   
Enter either 'Y' or 'N'.                        
Answer 'Yes' if the veteran is exempt from LTC copayments                       
for a reason other than low income.                     
Reason for Exemption                    
A reason for exemption must be entered.  LTC Copay Test cannot be added.                        
Veteran is NOT EXEMPT from Long Term Care copayments based                      
on last year's income and must complete a 10-10EC form.                 
Enter in this field the annual amount of Social Security                        
received during the current calendar year.                      
A monthly amount can be entered with an '*' after it.                   
Enter in this field the annual amount of U.S. Civil Service                     
Enter in this field the annual amount of Military Retirement                    
Enter in this field the annual amount of Other Retirement received                      
during the current calendar year.  This includes company, state,                        
Enter in this field the annual amount of Gross Income received during                   
the current year.  This includes, but is not limited to, wages and                      
income from a business, bonuses, tips, severance pay, accrued                   
benefits, cash gifts.                   
Enter in this field the annual amount of Net Income received during                     
the current calendar year from the operation of a farm, ranch,                  
property or business.                   
Enter in this field the annual amount of Interest and Dividend                  
Income received during the current calendar year (i.e., interest                        
income, standard dividend income from non tax deferred annuities).                      
Enter in this field the annual amount of Workers Compensation or                        
Black Lung Benefits received during the current calendar year.                  
Enter in this field the annual amount of All Other Income received                      
during the current calendar year, including retirement and pension                      
income, Social Security Retirement and Social Security Disability                       
income, compensation benefits such as unemployment, Workers and                 
Black Lung, or VA disability.  Also cash gifts, court mandated                  
payments, inheritance amounts, tort settlement payments, interest                       
and dividends, including tax exempt earnings and distributions from                     
Individual Retirement Accounts (IRAs) or annuities.                     
received during the current calendar year (i.e., inheritance amounts,                   
tort settlement payments).                      
Enter in this field the total amount of unreimbursed medical expenses                   
paid by the veteran during the current calendar year.  The expenses                     
can be for the veteran or for members of the veteran's family.                  
Reportable medical expenses include amounts paid for the following:                     
fees of physicians, dentists, and other providers of health services;                   
hospital and nursing home fees; medical insurance premiums (including                   
the Medicare premium); drugs and medicines; eyeglasses; any other                       
expenses that are reasonable related to medical care.  The expenses                     
must actually have been paid by the veteran.  Do not list expenses                      
which have not been paid or which have been paid by someone other                       
than the veteran.  Do not list expenses which the veteran has paid if                   
the veteran expects to receive reimbursement from insurance or some                     
other source.                   
calendar year for funeral or burial expenses of the veteran's                   
spouse or child, or pre-paid arrangements for the veteran.                      
Do not report amounts paid for funeral or burial expenses of other                      
relatives such as parents, siblings, etc.                       
Enter in this field the total amount paid by the veteran for                    
educational expenses during the current calendar year.  This                    
includes educational expenses for the veteran, spouse and children.                     
Educational expenses are tuition, fees, and books if enrolled in a                      
program of education.                   
Enter in this field cash and amounts in bank accounts.  This                    
includes checking accounts, savings accounts, money markets,                    
interest, dividends from IRA, 401K's, and other tax deferred                    
Enter in this field the current value of stocks, bonds, mutual                  
funds, SEP's, and other retirement accounts (e.g., IRA, 401K,                   
annuities, self-employed person).                       
 has no LTC copay (10-10EC) tests on file.                      
This LTC Copay Test (10-10EC) is uneditable and cannot be deleted.                      
Display test                    
    <OK, nothing deleted!>                      
  <LTC Copay Test deleted.>                     
Pat ID:                         
  LTC Copay Test Date   Status:                         
Source:                         
EASEC DEPENDENTS                        
Cannot edit when viewing a LTC copay test.                      
Not a LTC copay test - use LTC copay test options.                      
 as a dependent to the LTC copay test.                  
Not applicable for LTC copay test                       
Married This Year:                      
Legally Separated:                      
Spouse Residing in Community:                   
Living with Spouse:                     
Dependent Residing in Community:                        
Dependent Living with You:                      
EASEC EXPAND PROFILE                    
Select DATE OF LTC COPAY TEST:                  
Warning: Uneditable LTC Copay test.  The source of this test is                         
Would you like to view the LTC Copay test or print the 10-10EC                  
Enter a date that is less than or equal to today.                       
Enter the date of the LTC Copay Test.                   
Are you sure you want to change the date of the LTC Copay Test                  
must complete a 10-10EC form.                   
Report of LTC Copayment Tests                   
Enter 1 or 2                    
Indicate whether the report should include:                     
(1) a list of veterans whose LTC Copayment Test is pending expiration (i.e.,                    
the anniversary date of the test is approaching) within a user-specified                        
number of days, or                      
(2) a list of veterans whose LTC Copayment Test has already expired (i.e.,                      
the anniversary date of the test has passed) since a user-specified date.                       
Enter number of days to report                  
Enter a start date                      
Sort report by Name or Date                     
Indicate whether the report should be sorted by the                     
Veteran's Name or the LTC Copay Test Anniversary Date                   
Report Cancelled!                       
LTC COPAY TESTS                 
Report                  
Queued!                 
Cancelled!                      
*** No records to print ***                     
VETERANS WITH LONG TERM CARE COPAYMENT TESTS THAT                       
ARE PENDING EXPIRATION IN                       
HAVE EXPIRED SINCE                      
SORTED BY                       
REPORT DATE:                    
LTC Test                        
Veteran's Name                  
Anniversary Date                        
The income threshold check could not be completed due to an error.                      
Means Test                      
LTC Copay Exemption Test                        
The previous year's financial information is not on file for this veteran.                      
 is required.                   
 at this time                   
Report of Calculated Long Term Care Copayments                  
No LTC Copayment Test on file for this veteran!                 
Copayment rates for LTC are not available at this time.                 
The LTC Copayment Test is incomplete!                   
This veteran is Exempt from LTC copayments!                     
This LTC Copayment Test contains an invalid status!                     
Enter the LTC Admission Date                    
Enter the admission date for the current institutional                  
Long Term Care episode.                 
Enter the Report Start Date (Month/Year)                        
Enter the starting date for the report in the format month/year (e.g. 9/03).                    
The report will print 12 months of copayments starting with the                 
month and year entered.                 
Report Start Date cannot be before LTC Admission Date!                  
LTC Copay Calculation Report                    
SPOUSE RESIDING IN THE COMMUNITY                        
*** DECLINED TO PROVIDE INCOME INFORMATION -- AGREED TO PAY COPAYMENTS ***                      
*** VETERAN IS INELIGIBLE FOR LTC SERVICES -- REFUSED TO SIGN 10-10EC ***                       
LTC COPAY TEST DATE:                    
LTC ADMISSION DATE:                     
LTC COPAYMENT CALCULATION                       
FOR DAYS 1-180                          
FOR DAYS 181+                           
TOT ASSETS                      
TOT INCOME                      
TOT EXPENSES                    
TOT ALLOWANCE                   
CALC COPAY                      
MAX COPAY                       
VET COPAY                       
LONG TERM CARE ESTIMATED COPAYMENTS FOR                         
NON-                    
INSTITUTIONAL SERVICES                  
TOTAL INCOME - TOTAL EXPENSES - TOTAL ALLOWANCE                 
(TOTAL ASSETS + TOTAL INCOME) - TOTAL EXPENSES - TOTAL ALLOWANCE                        
(TOTAL ASSETS + TOTAL INCOME) - TOTAL ALLOWANCE                 
IMPORTANT NOTICE: The copayment amounts shown in this report are                        
based on calculations of the copayment amount for                       
an entire month. The                    
copayment amounts will be adjusted to                   
reflect the actual start date of LTC                    
services and the                        
copayment exemption for the first 21 days of service. The VET                   
COPAY amount is based on the assumption that the veteran                        
will be responsible                     
to pay the lesser of EITHER the calculated                      
 copayment (CALC COPAY) OR the                  
maximum copayment (MAX COPAY).                          
In the event that the calculated copayment                      
(CALC COPAY) is a                       
negative figure, the veteran copayment (VET COPAY)                      
will be adjusted to zero (0). If the veteran declined to provide                        
information, the veteran will be obligated to pay the                   
 maximum copayment.                     
EXPLANATION OF ASSET SPEND DOWN CALCULATION:                    
The veteran's assets are included in the calculation of copayments                      
after 180 days of institutional LTC services.  The assets then may                      
be reduced each month according to the following formula:                       
Single Veteran:                 
  TOTAL ASSETS-(VET COPAY-(INCOME-ALLOWANCE))                   
Married Veteran (spouse residing in the community):                     
  TOTAL ASSETS-(VET COPAY-(INCOME-EXPENSES-ALLOWANCE))                  
In other words, the assets will be reduced by the amount of the                 
veteran's copayment that is not covered by the veteran's income                         
after all expenses and allowances are subtracted.  If the amount                        
of the veteran's income after all expenses and allowances are                   
####################    ####################    ####################    
####################    ####################    ####################    
####################    ####################    ####################    
####################    ####################    ####################    
####################    ####################    ####################