EASEC102 ;ALB/BRM - Print 1010EC LTC Enrollment form ; 9/20/01 12:25pm
;;1.0;ENROLLMENT APPLICATION SYSTEM;**5,7**;Mar 15, 2001
;
; Called from ^EASEC10E to print page 2 of the 1010EC
;
PAGE2(EALNE,EAINFO,EASDFN) ;Print page 2
N X,EASROOT
S EASROOT="^TMP(""1010EC"",$J,"_EASDFN_","
D HDR^EASEC10E(.EALNE,.EAINFO)
D SIGN
D SEC4
D SEC5
D FT^EASEC10E(.EALNE,.EAINFO)
Q
SIGN ;print disclaimer and signature block to refuse income data
;
W !,"I do not wish to provide my detailed financial information. "
W "I understand that I will be assessed the maximum copayment amount for"
W !,"extended care services and agree to pay the applicable VA copayment as required by law.",?131,$C(13) X EAINFO("L")
W !,"Signature",?100,"| Date",!?100,"|",?131,$C(13) X EAINFO("L")
Q
;
SEC4 ; print section 4 - Fixed Assets (Veteran and Spouse)
N EAS4
S EAS4=EASROOT_"4)"
W !?23,"SECTION IV - FIXED ASSETS (VETERAN AND SPOUSE)",?100,"|",?113,"VALUE",!,EALNE("D")
;
W !,"1. Residence (Market value minus any outstanding mortgage or "
W "lien - exclude if veteran",?100,"|",?105,"$",$J(@EAS4@(1),12,2)
W !?3,"receiving only non-institutional services or spouse or "
W "dependent residing in community).",?100,"|",?131,$C(13) X EAINFO("L")
;
W !,"2. Other Residences/Land/Farm or Ranch (Market value minus any "
W "outstanding mortgage or lien)",?100,"|",?105,"$",$J(@EAS4@(2),12,2),?131,$C(13) X EAINFO("L")
;
W !,"3. Vehicle(s)* (Value minus any outstanding lien - exclude if veteran is "
W "receiving only",?100,"|",?105,"$",$J(@EAS4@(3),12,2)
W !?3,"non-institutional services or spouse or dependent residing in community).",?100,"|",?131,$C(13) X EAINFO("L")
;
W !?62,"| SUBTOTAL (Sum of lines 1 through 3)",?100,"|",?105,"$",$J(@EAS4@(4),12,2),?131,$C(13) X EAINFO("L")
Q
SEC5 ; print section 5 - Liquid Assets (Veteran and Spouse)
N EAS5
S EAS5=EASROOT_"5)"
W !?23,"SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE)",?100,"|",?113,"VALUE",!,EALNE("D")
;
W !,"1. Cash, e.g., interest, dividends from IRA, 401K's and other "
W "tax deferred annuities ",?100,"|",?105,"$",$J(@EAS5@(1),12,2)
W !?3,"(including checking, savings, money market, etc.)"
W ?100,"|",?131,$C(13) X EAINFO("L")
;
W !,"2. Stocks, bonds, mutual funds, SEP's, and other retirement "
W "accounts (e.g., IRA, 401K,",?100,"|",?105,"$",$J(@EAS5@(2),12,2)
W !?3,"annuities, self-employed person)",?100,"|",?131,$C(13) X EAINFO("L")
;
W !,"3. Other Liquid Assets (Includes such items as stamp or coin "
W "collections, art work, collectibles",?100,"|"
W !?3,"household furniture and other household goods, clothing, jewelry, and "
W "personal items",?100,"|",?105,"$",$J(@EAS5@(3),12,2)
W !?3,"minus amount owed).",?100,"|",?131,$C(13) X EAINFO("L")
;
W !?62,"| SUBTOTAL (Sum of lines 1 through 3)",?100,"|",?105,"$",$J(@EAS5@(4),12,2),?131,$C(13) X EAINFO("L")
;
W !,"SUM OF ALL LINES FIXED AND LIQUID ASSETS",?62,"|"
W ?83,"TOTAL ASSETS",?100,"|",?105,"$",$J(@EAS5@(5),12,2),?131,$C(13) X EAINFO("L")
;
W !?45,"CATEGORY",?97,"|",?102,"VETERAN",?113,"|",?119,"SPOUSE",?131,$C(13) X EAINFO("L")
;
W !,"Current income, e.g. gross income (including, but not limited "
W "to, wages and income from",?97,"| $",$J(@EAS5@(6),10,2),?113,"| $",$J(@EAS5@(7),10,2)
W !,"a business, bonuses, tips, severance pay, accrued benefits, "
W "cash gifts)",?97,"|",?113,"|",?131,$C(13) X EAINFO("L")
;
W !,"Social Security Retirement/Disability",?97,"| $",$J(@EAS5@(8),10,2),?113,"| $",$J(@EAS5@(9),10,2),?131,$C(13) X EAINFO("L")
;
W !,"Interest/Dividends (i.e., interest income, standard dividend "
W "income from non tax deferred",?97,"| $",$J(@EAS5@(10),10,2),?113,"| $",$J(@EAS5@(11),10,2)
W !,"annuities)",?97,"|",?113,"|",?131,$C(13) X EAINFO("L")
;
W !,"Retirement and Pension income",?97,"| $",$J(@EAS5@(12),10,2),?113,"| $",$J(@EAS5@(13),10,2),?131,$C(13) X EAINFO("L")
;
W !,"Civil Service Retirement",?97,"| $",$J(@EAS5@(14),10,2),?113,"| $",$J(@EAS5@(15),10,2),?131,$C(13) X EAINFO("L")
;
W !,"US Railroad Retirement",?97,"| $",$J(@EAS5@(16),10,2),?113,"| $",$J(@EAS5@(17),10,2),?131,$C(13) X EAINFO("L")
;
W !,"VA Pension",?97,"| $",$J(@EAS5@(18),10,2),?113,"| $",$J(@EAS5@(19),10,2),?131,$C(13) X EAINFO("L")
;
W !,"Spouse VA disability/compensation",?97,"| $",$J(@EAS5@(20),10,2),?113,"| $",$J(@EAS5@(21),10,2),?131,$C(13) X EAINFO("L")
;
W !,"Unemployment Benefits/Compensation",?97,"| $",$J(@EAS5@(22),10,2),?113,"| $",$J(@EAS5@(23),10,2),?131,$C(13) X EAINFO("L")
;
W !,"Other compensation, e.g. Workers Compensation and Black Lung",?97,"| $",$J(@EAS5@(24),10,2),?113,"| $",$J(@EAS5@(25),10,2),?131,$C(13) X EAINFO("L")
;
W !,"Military Retirement",?97,"| $",$J(@EAS5@(26),10,2),?113,"| $",$J(@EAS5@(27),10,2),?131,$C(13) X EAINFO("L")
;
W !,"Other Retirement",?97,"| $",$J(@EAS5@(28),10,2),?113,"| $",$J(@EAS5@(29),10,2),?131,$C(13) X EAINFO("L")
;
W !,"Court Mandated (e.g. alimony, child support) (Veteran and Spouse)",?97,"| $",$J(@EAS5@(30),10,2),?113,"| $",$J(@EAS5@(31),10,2),?131,$C(13) X EAINFO("L")
;
W !,"Other Income (i.e., inheritance amounts, tort settlement "
W "payments)",?97,"| $",$J(@EAS5@(32),10,2),?113,"| $",$J(@EAS5@(33),10,2),?131,$C(13) X EAINFO("L")
W !,?82,"| TOTALS",?97,"| $",$J(@EAS5@(34),10,2),?113,"| $",$J(@EAS5@(35),10,2)
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HEASEC102 5404 printed Apr 09, 2024@20:58:24 Page 2
EASEC102 ;ALB/BRM - Print 1010EC LTC Enrollment form ; 9/20/01 12:25pm
+1 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**5,7**;Mar 15, 2001
+2 ;
+3 ; Called from ^EASEC10E to print page 2 of the 1010EC
+4 ;
PAGE2(EALNE,EAINFO,EASDFN) ;Print page 2
+1 NEW X,EASROOT
+2 SET EASROOT="^TMP(""1010EC"",$J,"_EASDFN_","
+3 DO HDR^EASEC10E(.EALNE,.EAINFO)
+4 DO SIGN
+5 DO SEC4
+6 DO SEC5
+7 DO FT^EASEC10E(.EALNE,.EAINFO)
+8 QUIT
SIGN ;print disclaimer and signature block to refuse income data
+1 ;
+2 WRITE !,"I do not wish to provide my detailed financial information. "
+3 WRITE "I understand that I will be assessed the maximum copayment amount for"
+4 WRITE !,"extended care services and agree to pay the applicable VA copayment as required by law.",?131,$CHAR(13)
XECUTE EAINFO("L")
+5 WRITE !,"Signature",?100,"| Date",!?100,"|",?131,$CHAR(13)
XECUTE EAINFO("L")
+6 QUIT
+7 ;
SEC4 ; print section 4 - Fixed Assets (Veteran and Spouse)
+1 NEW EAS4
+2 SET EAS4=EASROOT_"4)"
+3 WRITE !?23,"SECTION IV - FIXED ASSETS (VETERAN AND SPOUSE)",?100,"|",?113,"VALUE",!,EALNE("D")
+4 ;
+5 WRITE !,"1. Residence (Market value minus any outstanding mortgage or "
+6 WRITE "lien - exclude if veteran",?100,"|",?105,"$",$JUSTIFY(@EAS4@(1),12,2)
+7 WRITE !?3,"receiving only non-institutional services or spouse or "
+8 WRITE "dependent residing in community).",?100,"|",?131,$CHAR(13)
XECUTE EAINFO("L")
+9 ;
+10 WRITE !,"2. Other Residences/Land/Farm or Ranch (Market value minus any "
+11 WRITE "outstanding mortgage or lien)",?100,"|",?105,"$",$JUSTIFY(@EAS4@(2),12,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+12 ;
+13 WRITE !,"3. Vehicle(s)* (Value minus any outstanding lien - exclude if veteran is "
+14 WRITE "receiving only",?100,"|",?105,"$",$JUSTIFY(@EAS4@(3),12,2)
+15 WRITE !?3,"non-institutional services or spouse or dependent residing in community).",?100,"|",?131,$CHAR(13)
XECUTE EAINFO("L")
+16 ;
+17 WRITE !?62,"| SUBTOTAL (Sum of lines 1 through 3)",?100,"|",?105,"$",$JUSTIFY(@EAS4@(4),12,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+18 QUIT
SEC5 ; print section 5 - Liquid Assets (Veteran and Spouse)
+1 NEW EAS5
+2 SET EAS5=EASROOT_"5)"
+3 WRITE !?23,"SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE)",?100,"|",?113,"VALUE",!,EALNE("D")
+4 ;
+5 WRITE !,"1. Cash, e.g., interest, dividends from IRA, 401K's and other "
+6 WRITE "tax deferred annuities ",?100,"|",?105,"$",$JUSTIFY(@EAS5@(1),12,2)
+7 WRITE !?3,"(including checking, savings, money market, etc.)"
+8 WRITE ?100,"|",?131,$CHAR(13)
XECUTE EAINFO("L")
+9 ;
+10 WRITE !,"2. Stocks, bonds, mutual funds, SEP's, and other retirement "
+11 WRITE "accounts (e.g., IRA, 401K,",?100,"|",?105,"$",$JUSTIFY(@EAS5@(2),12,2)
+12 WRITE !?3,"annuities, self-employed person)",?100,"|",?131,$CHAR(13)
XECUTE EAINFO("L")
+13 ;
+14 WRITE !,"3. Other Liquid Assets (Includes such items as stamp or coin "
+15 WRITE "collections, art work, collectibles",?100,"|"
+16 WRITE !?3,"household furniture and other household goods, clothing, jewelry, and "
+17 WRITE "personal items",?100,"|",?105,"$",$JUSTIFY(@EAS5@(3),12,2)
+18 WRITE !?3,"minus amount owed).",?100,"|",?131,$CHAR(13)
XECUTE EAINFO("L")
+19 ;
+20 WRITE !?62,"| SUBTOTAL (Sum of lines 1 through 3)",?100,"|",?105,"$",$JUSTIFY(@EAS5@(4),12,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+21 ;
+22 WRITE !,"SUM OF ALL LINES FIXED AND LIQUID ASSETS",?62,"|"
+23 WRITE ?83,"TOTAL ASSETS",?100,"|",?105,"$",$JUSTIFY(@EAS5@(5),12,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+24 ;
+25 WRITE !?45,"CATEGORY",?97,"|",?102,"VETERAN",?113,"|",?119,"SPOUSE",?131,$CHAR(13)
XECUTE EAINFO("L")
+26 ;
+27 WRITE !,"Current income, e.g. gross income (including, but not limited "
+28 WRITE "to, wages and income from",?97,"| $",$JUSTIFY(@EAS5@(6),10,2),?113,"| $",$JUSTIFY(@EAS5@(7),10,2)
+29 WRITE !,"a business, bonuses, tips, severance pay, accrued benefits, "
+30 WRITE "cash gifts)",?97,"|",?113,"|",?131,$CHAR(13)
XECUTE EAINFO("L")
+31 ;
+32 WRITE !,"Social Security Retirement/Disability",?97,"| $",$JUSTIFY(@EAS5@(8),10,2),?113,"| $",$JUSTIFY(@EAS5@(9),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+33 ;
+34 WRITE !,"Interest/Dividends (i.e., interest income, standard dividend "
+35 WRITE "income from non tax deferred",?97,"| $",$JUSTIFY(@EAS5@(10),10,2),?113,"| $",$JUSTIFY(@EAS5@(11),10,2)
+36 WRITE !,"annuities)",?97,"|",?113,"|",?131,$CHAR(13)
XECUTE EAINFO("L")
+37 ;
+38 WRITE !,"Retirement and Pension income",?97,"| $",$JUSTIFY(@EAS5@(12),10,2),?113,"| $",$JUSTIFY(@EAS5@(13),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+39 ;
+40 WRITE !,"Civil Service Retirement",?97,"| $",$JUSTIFY(@EAS5@(14),10,2),?113,"| $",$JUSTIFY(@EAS5@(15),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+41 ;
+42 WRITE !,"US Railroad Retirement",?97,"| $",$JUSTIFY(@EAS5@(16),10,2),?113,"| $",$JUSTIFY(@EAS5@(17),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+43 ;
+44 WRITE !,"VA Pension",?97,"| $",$JUSTIFY(@EAS5@(18),10,2),?113,"| $",$JUSTIFY(@EAS5@(19),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+45 ;
+46 WRITE !,"Spouse VA disability/compensation",?97,"| $",$JUSTIFY(@EAS5@(20),10,2),?113,"| $",$JUSTIFY(@EAS5@(21),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+47 ;
+48 WRITE !,"Unemployment Benefits/Compensation",?97,"| $",$JUSTIFY(@EAS5@(22),10,2),?113,"| $",$JUSTIFY(@EAS5@(23),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+49 ;
+50 WRITE !,"Other compensation, e.g. Workers Compensation and Black Lung",?97,"| $",$JUSTIFY(@EAS5@(24),10,2),?113,"| $",$JUSTIFY(@EAS5@(25),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+51 ;
+52 WRITE !,"Military Retirement",?97,"| $",$JUSTIFY(@EAS5@(26),10,2),?113,"| $",$JUSTIFY(@EAS5@(27),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+53 ;
+54 WRITE !,"Other Retirement",?97,"| $",$JUSTIFY(@EAS5@(28),10,2),?113,"| $",$JUSTIFY(@EAS5@(29),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+55 ;
+56 WRITE !,"Court Mandated (e.g. alimony, child support) (Veteran and Spouse)",?97,"| $",$JUSTIFY(@EAS5@(30),10,2),?113,"| $",$JUSTIFY(@EAS5@(31),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+57 ;
+58 WRITE !,"Other Income (i.e., inheritance amounts, tort settlement "
+59 WRITE "payments)",?97,"| $",$JUSTIFY(@EAS5@(32),10,2),?113,"| $",$JUSTIFY(@EAS5@(33),10,2),?131,$CHAR(13)
XECUTE EAINFO("L")
+60 WRITE !,?82,"| TOTALS",?97,"| $",$JUSTIFY(@EAS5@(34),10,2),?113,"| $",$JUSTIFY(@EAS5@(35),10,2)
+61 QUIT
