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Routine: EASEC10R

Package: Enrollment Application System

Routine: EASEC10R


Information

EASEC10R ;ALB/LBD - Print 1010EC LTC Enrollment form ; 9/20/01 12:25pm

Source Information

Source file <EASEC10R.m>

Entry Points

Name Comments DBIA/ICR reference
PAGE2(EALNE,EAINFO,EASDFN) ;Print page 2 of revised 1010EC
SIGN ;print disclaimer and signature block to refuse income data
SEC4 ; print section 4 - Fixed Assets (Veteran and Spouse)
SEC5 ; print section 5 - Liquid Assets (Veteran and Spouse)
SEC7 ; print section 7 - Expenses
; Expenses are in section 7 on the new 10-10EC (section 6 on the old)
PAGE3(EALNE,EAINFO,EASDFN) ;Print page 3
SEC8 ; print section 8 - Consent for Assignment of Benefits
; (section 7 on old 10-10EC form)
SEC9 ;print section 9 - Consent to Agreement to Make Copayments
; (section 8 on old 10-10EC form)
SEC10 ; print section 10 - Paperwork Privacy Act Information

Interaction Calls

Name Line Occurrences
Function Call: WRITE
  • Prompt: !,"I do not wish to provide my detailed financial information. "
  • Line Location: SIGN+2
Function Call: WRITE
  • Prompt: "I understand that I will be assessed the maximum copayment amount for"
  • Line Location: SIGN+3
Function Call: WRITE
  • Prompt: !,"extended care services and agree to pay the applicable VA copayment as required by law.",?131,$C(13)
  • Line Location: SIGN+4
Function Call: WRITE
  • Prompt: !,"Signature",?97,"| Date",!?97,"|",?131,$C(13)
  • Line Location: SIGN+5
Function Call: WRITE
  • Prompt: !?23,"SECTION IV - FIXED ASSETS (VETERAN AND SPOUSE)",?97,"|",?102,"VETERAN",?113,"|",?119,"SPOUSE",?131,$C(13)
  • Line Location: SEC4+3
Function Call: WRITE
  • Prompt: !,"1. Primary Residence (Market value minus mortgages or liens. "
  • Line Location: SEC4+5
Function Call: WRITE
  • Prompt: "Exclude if veteran receiving only",?97,"| $",$J(@EAS4@(1),12,2),?113,"| $",$J(@EAS4@(1.5),12,2)
  • Line Location: SEC4+6
Function Call: WRITE
  • Prompt: !?3,"non-institutional extended care services or spouse or dependent residing in community. If the",?97,"|",?113,"|"
  • Line Location: SEC4+7
Function Call: WRITE
  • Prompt: !?3,"veteran and spouse maintain separate residences, and the veteran is receiving institutional",?97,"|",?113,"|"
  • Line Location: SEC4+8
Function Call: WRITE
  • Prompt: !?3,"(inpatient) extended care services, include value of the veteran's primary residence.)",?97,"|",?113,"|",?131,$C(13)
  • Line Location: SEC4+9
Function Call: WRITE
  • Prompt: !,"2. Other Residences/Land/Farm or Ranch (Market value minus mortgages or liens. "
  • Line Location: SEC4+11
Function Call: WRITE
  • Prompt: "This would",?97,"| $",$J(@EAS4@(2),12,2),?113,"| $",$J(@EAS4@(2.5),12,2)
  • Line Location: SEC4+12
Function Call: WRITE
  • Prompt: !?3,"include a second home, vacation home, rental property.)",?97,"|",?113,"|",?131,$C(13)
  • Line Location: SEC4+13
Function Call: WRITE
  • Prompt: !,"3. Vehicle(s) (Value minus outstanding lien. Exclude primary vehicle if veteran "
  • Line Location: SEC4+15
Function Call: WRITE
  • Prompt: "receiving only",?97,"| $",$J(@EAS4@(3),12,2),?113,"| $",$J(@EAS4@(3.5),12,2)
  • Line Location: SEC4+16
Function Call: WRITE
  • Prompt: !?3,"non-institutional extended care services or spouse or dependent residing in community. If the",?97,"|",?113,"|"
  • Line Location: SEC4+17
Function Call: WRITE
  • Prompt: !?3,"veteran and spouse maintain separate residences and vehicles, and the veteran is receiving",?97,"|",?113,"|"
  • Line Location: SEC4+18
Function Call: WRITE
  • Prompt: !?3,"institutional (inpatient) extended care services, include value of veteran's primary vehicle.)",?97,"|",?113,"|",?131,$C(13)
  • Line Location: SEC4+19
Function Call: WRITE
  • Prompt: !?23,"SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE)",?97,"|",?113,"|",?131
  • Line Location: SEC5+3
Function Call: WRITE
  • Prompt: !,"1. Cash, Amount in Bank Accounts (e.g., checking and savings accounts, certificates "
  • Line Location: SEC5+5
Function Call: WRITE
  • Prompt: "of deposit",?97,"| $",$J(@EAS5@(1),12,2),?113,"| $",$J(@EAS5@(1.5),12,2)
  • Line Location: SEC5+6
Function Call: WRITE
  • Prompt: !?3,"individual retirement accounts, stocks and bonds.)"
  • Line Location: SEC5+7
Function Call: WRITE
  • Prompt: ?97,"|",?113,"|",?131,$C(13)
  • Line Location: SEC5+8
Function Call: WRITE
  • Prompt: !,"2. Value of Other Liquid Assets (e.g., art, rare coins, stamp collections, collectibles) Minus"
  • Line Location: SEC5+10
Function Call: WRITE
  • Prompt: ?97,"| $",$J(@EAS5@(3),12,2),?113,"| $",$J(@EAS5@(3.5),12,2)
  • Line Location: SEC5+11
Function Call: WRITE
  • Prompt: !?3,"the amount you owe on these items. Exclude household effects, clothing, jewelry, and personal",?97,"|",?113,"|"
  • Line Location: SEC5+12
Function Call: WRITE
  • Prompt: !?3,"items if veteran receiving only non-institutional extended care services or spouse or",?97,"|",?113,"|"
  • Line Location: SEC5+13
Function Call: WRITE
  • Prompt: !?3,"dependent residing in the community.",?97,"|",?113,"|",?131,$C(13)
  • Line Location: SEC5+14
Function Call: WRITE
  • Prompt: !," SUM OF ALL LINES FIXED AND LIQUID ASSETS"
  • Line Location: SEC5+16
Function Call: WRITE
  • Prompt: ?75,"| TOTAL ASSETS",?97,"| $",$J(@EAS5@(5),12,2),?113,"| $",$J(@EAS5@(5.5),12,2),?131,$C(13)
  • Line Location: SEC5+17
Function Call: WRITE
  • Prompt: !?23,"SECTION VI - CURRENT GROSS INCOME OF VETERAN AND SPOUSE",?97,"|",?113,"|",?131
  • Line Location: SEC5+20
Function Call: WRITE
  • Prompt: !?45,"CATEGORY",?97,"|",?102,"VETERAN",?113,"|",?119,"SPOUSE",?131,$C(13)
  • Line Location: SEC5+21
Function Call: WRITE
  • Prompt: !,"1. Gross annual income from employment (e.g., wages, bonuses, tips, severance pay"
  • Line Location: SEC5+23
Function Call: WRITE
  • Prompt: ?97,"| $",$J(@EAS5@(6),10,2),?113,"| $",$J(@EAS5@(7),10,2)
  • Line Location: SEC5+24
Function Call: WRITE
  • Prompt: !,"accrued benefits)",?97,"|",?113,"|",?131,$C(13)
  • Line Location: SEC5+25
Function Call: WRITE
  • Prompt: !,"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)
  • Line Location: SEC5+27
Function Call: WRITE
  • Prompt: !,"3. List other income amounts (e.g., Social Security, retirement and pension, ",?97,"| $",$J(@EAS5@(32),10,2),?113,"| $",$J(@EAS5@(33),10,2)
  • Line Location: SEC5+29
Function Call: WRITE
  • Prompt: !?3,"interest, dividends) Refer to instructions.",?97,"|",?113,"|",?131,$C(13)
  • Line Location: SEC5+30
Function Call: WRITE
  • Prompt: !?43,"SECTION VII - DEDUCTIBLE EXPENSES",!,EALNE("D")
  • Line Location: SEC7+5
Function Call: WRITE
  • Prompt: !?54,"ITEMS",?113,"|",?119,"AMOUNT",?131,$C(13)
  • Line Location: SEC7+6
Function Call: WRITE
  • Prompt: !,"1. Educational expenses of veteran, spouse or dependent (e.g., tuition, books, fees, material, etc.)",?113,"| $",$J(@EAS6@(1),10,2),?131,$C(13)
  • Line Location: SEC7+7
Function Call: WRITE
  • Prompt: !,"2. Funeral and Burial (spouse or child, amount you paid for funeral and burial expenses, including prepaid",?113,"| $",$J(@EAS6@(2),10,2)
  • Line Location: SEC7+8
Function Call: WRITE
  • Prompt: !?3,"arrangements)",?113,"|",?131,$C(13)
  • Line Location: SEC7+9
Function Call: WRITE
  • Prompt: !,"3. Rent/Mortgage (monthly amount or annual amount)",?113,"| $",$J(@EAS6@(3),10,2),?131,$C(13)
  • Line Location: SEC7+10
Function Call: WRITE
  • Prompt: !,"4. Utilities (calculate by average monthly amounts over the past 12 months)",?113,"| $",$J(@EAS6@(4),10,2),?131,$C(13)
  • Line Location: SEC7+11
Function Call: WRITE
  • Prompt: !,"5. Car Payment for one vehicle only (exclude gas, automobile insurance, parking fees, repairs)",?113,"| $",$J(@EAS6@(5),10,2),?131,$C(13)
  • Line Location: SEC7+12
Function Call: WRITE
  • Prompt: !,"6. Food (for veteran, spouse and dependent)",?113,"| $",$J(@EAS6@(6),10,2),?131,$C(13)
  • Line Location: SEC7+13
Function Call: WRITE
  • Prompt: !,"7. Non-reimbursed medical expenses paid by you or spouse (e.g., copayments for physicians, dentists,",?113,"| $",$J(@EAS6@(7),10,2)
  • Line Location: SEC7+14
Function Call: WRITE
  • Prompt: !?3,"medications, Medicare, health insurance, hospital and nursing home expenses)",?113,"|",?131,$C(13)
  • Line Location: SEC7+15
Function Call: WRITE
  • Prompt: !,"8. Court-ordered payments (e.g., alimony, child support)",?113,"| $",$J(@EAS6@(8),10,2),?131,$C(13)
  • Line Location: SEC7+16
Function Call: WRITE
  • Prompt: !,"9. Insurance (e.g., automobile insurance, homeowners insurance) Exclude life insurance",?113,"| $",$J(@EAS6@(9),10,2),?131,$C(13)
  • Line Location: SEC7+17
Function Call: WRITE
  • Prompt: !,"10. Taxes (e.g., personal property for home, automobile) Include average monthly expense for taxes paid on",?113,"| $",$J(@EAS6@(10),10,2)
  • Line Location: SEC7+18
Function Call: WRITE
  • Prompt: !?3,"income over the past 12 months.",?113,"|",?131,$C(13)
  • Line Location: SEC7+19
Function Call: WRITE
  • Prompt: !,?95,"| TOTAL",?113,"| $",$J(@EAS6@(11),10,2),?131
  • Line Location: SEC7+20
Function Call: WRITE
  • Prompt: !?43,"SECTION X - PAPERWORK PRIVACY ACT INFORMATION",!,EALNE("D")
  • Line Location: SEC10+3
Function Call: WRITE
  • Prompt: !,"The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance"
  • Line Location: SEC10+4
Function Call: WRITE
  • Prompt: !,"requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to"
  • Line Location: SEC10+5
Function Call: WRITE
  • Prompt: !,"respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all"
  • Line Location: SEC10+6
Function Call: WRITE
  • Prompt: !,"individuals who must complete this form will average 90 minutes. This includes the time it will take to read instructions, gather"
  • Line Location: SEC10+7
Function Call: WRITE
  • Prompt: !,"the necessary facts and fill out the form. If you have comments regarding this burden estimate or any other aspect of this"
  • Line Location: SEC10+8
Function Call: WRITE
  • Prompt: !,"collection, call 202.273.8247 for mailing information on where to send your comments.",!
  • Line Location: SEC10+9
Function Call: WRITE
  • Prompt: !,"Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code,"
  • Line Location: SEC10+10
Function Call: WRITE
  • Prompt: !,"sections 1710, 1712, 1722 and 1729 in order for VA to determine your eligibility for extended care benefits and to establish"
  • Line Location: SEC10+11
Function Call: WRITE
  • Prompt: !,"financial eligibility, if applicable, when placed in extended care services. The information you supply may be verified through a"
  • Line Location: SEC10+12
Function Call: WRITE
  • Prompt: !,"computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a"
  • Line Location: SEC10+13
Function Call: WRITE
  • Prompt: !,"""routine use"" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the"
  • Line Location: SEC10+14
Function Call: WRITE
  • Prompt: !,"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"
  • Line Location: SEC10+15
Function Call: WRITE
  • Prompt: !,"your request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to"
  • Line Location: SEC10+16
Function Call: WRITE
  • Prompt: !,"which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may"
  • Line Location: SEC10+17
Function Call: WRITE
  • Prompt: !,"also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other"
  • Line Location: SEC10+18
Function Call: WRITE
  • Prompt: !,"purposes authorized or required by law.",?131,$C(13)
  • Line Location: SEC10+19
Function Call: WRITE
  • Prompt: !,"Additional Comments:"
  • Line Location: SEC10+20
Function Call: WRITE
  • Prompt: !,@EAS8@(WPLINE)
  • Line Location: SEC10+22
Function Call: WRITE
  • Prompt: !
  • Line Location: SEC10+23
Info |  Source |  Entry Points |  Interaction Calls