EASEZPF2 ;ALB/SCK - Print 1010EZ Enrollment Form Cont., Page 2 ; 10/19/2000
;;1.0;ENROLLMENT APPLICATION SYSTEM;;Mar 15, 2001
;
EN(EALNE,EAINFO) ; Main entry point
; Input
; EALNE - Array of line formats for output
; EAINFO - Application Data array, see SETUP^EASEZPF
;
N EASD
;
D HDR^EASEZPF(.EALNE,.EAINFO)
W !,?50,"SECTION II - FINANCIAL ASSESSMENT",!,EALNE("DD")
;
S EASD="^TMP(""EASEZ"",$J,2)"
;
D DEP
D FIN
D INC
D EXP
D NET
;
D FT^EASEZPF(.EALNE,.EAINFO)
Q
;
DEP ; Print out VA 10-10EZ Section IIA, Dependent Information
W !,?52,"IIA - DEPENDENT INFORMATION",!,EALNE("D")
W !,"1. Spouse's Name ",@EASD@(1),?65,"|2. Child's Name ",@EASD@(2)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"3. Spouse's Social Security Number ",$P(@EASD@(3),U),?50,"|4. Spouse's Date Of Birth ",@EASD@(4),?90,"|5. Child's Date Of Birth ",@EASD@(5)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"6. Spouse's Address",?65,"|7. Child's Social Security Number"
W !?1,$P(@EASD@(6),U),?65,"| ",@EASD@(7)
W !?1,$P(@EASD@(6),U,2),?65,"|"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"8. Spouse's Telephone Number ",@EASD@(8),?65,"|9. Child's Relationship To You ",@EASD@(9)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"10. Date of Marriage ",@EASD@(10),?65,"|11. Date Child Became Your Dependent ",@EASD@(11)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
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"
W !,"Year, Enter the Amount you Contributed To Their Support",?65,"|Rehabilitation or Training (tuition, books, materials, etc.)"
;
W !?4,"Spouse $ ",$P(@EASD@(12),U),?26,"Child $ ",$P(@EASD@(12),U,2),?65,"| $ ",@EASD@(13)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"14. Was Child Permanently And Totally Disabled Before",?65,"|15. If Child is Between 18 and 23 Years Of Age, Did Child"
W !,"The Age Of 18? ",@EASD@(14),?65,"| Attend School Last Calendar Year? ",@EASD@(15)
Q
;
FIN ; Print out VA 10-10EZ Section IIB, Financial Disclosure information
W !,EALNE("DD")
W !,?50,"IIB - FINANCIAL DISCLOSURE"
W !,"You are not required to provide the financial information in this Section. However, current law may require VA to consider your"
W !,"household financial situation to determine your eligibility for enrollment and/or cost-free care of your nonservice-connected"
W !,"(NSC) conditions. If you are 0% SC noncompensable or NSC (and are not an Ex-POW, WWI veteran or VA pensioner) and your"
W !,"annual household income (or combined income net worth) exceeds the established threshold, you must agree to pay VA co-payments"
W !,"for care of your NSC conditions to be eligible for enrollment. See Section III - Consent and Signature"
;
S (EAY,EAN)="___"
S:EAINFO("DISC")="YES" EAY=" X "
S:EAINFO("DISC")="NO" EAN=" X "
;
W !!?4,EAY," YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO HAVE ELIGIBILITY FOR CARE DETERMINED. Complete all"
W !?8,"sections below that apply to you with last calendar year's information. Sign and date the application."
W !?4,EAN," NO, I DO NOT WISH TO PROVIDE MY DETAILED FINANCIAL INFORMATION. I understand I will be assigned the appropriate enrollment"
W !?8,"priority based on nondisclosure of my financial information. By checking NO and signing below, I am agreeing to pay the"
W !?8,"applicable VA co-payment. Sign and date the application."
Q
;
INC ; Print out VA 10-10EZ Section IIC, Gross Annual Income information
W !,EALNE("DD")
W !?17,"IIC - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN"
;
W !?73,"| VETERAN",?90,"| SPOUSE",?110,"| CHILDREN"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"1. What Was Your Gross Annual Income From Employment (wages, bonuses,"
W !,"tips, etc), As Well as Income From Your Farm, Ranch, Property or Business",?73,"| $ "
W $P(@EASD@("2C1"),U),?90,"| $ ",$P(@EASD@("2C1"),U,2),?110,"| $ ",$P(@EASD@("2C1"),U,3)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"2. List Other Income Amounts (Social Security, compensation, pension,"
W !,"interest, dividends) Exclude Welfare.",?73,"| $ "
W $P(@EASD@("2C2"),U),?90,"| $ ",$P(@EASD@("2C2"),U,2),?110,"| $ ",$P(@EASD@("2C2"),U,3)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"3. Was Income From Your Farm, Ranch, Property or Business (if yes, refer to page 2, Section IIC of the instructions.) ",@EASD@("2C3")
;
Q
;
EXP ; Print out VA 10-10EZ Section IID, Deductible Expense Information
W !,EALNE("DD")
W !?50,"IID - DEDUCTIBLE EXPENSES"
W !,"1. Non-Reimbursed Medical Expenses Paid By You or Your Spouse (payments for doctors, dentists, drugs,"
W !,"Medicare, health insurance, hospital and nursing home)",?110,"| $ ",@EASD@("2D1")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"2. Amount You Paid Last Calendar Year For Funeral And Burial Expenses For Deceased Spouse or Dependent"
W !,"Child (also enter spouse or child's information in Section IIA)",?110,"| $ ",@EASD@("2D2")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"3. Amount You Paid Last Calendar Year For YOUR College or Vocational Educational Expenses (tutition, books,"
W !,"fees, materials, etc.) Do Not List Your Dependent's Educational Expenses.",?110,"| $ ",@EASD@("2D3")
;
Q
NET ; Print out VA 10-10EZ Section IIE, Net Worth Information
W !,EALNE("DD")
W !?50,"IIE - NET WORTH"
W !?91,"| VETERAN",?110,"| SPOUSE"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"1. Cash, Amount In Bank Accounts (checking and savings accounts, certificates of deposit,"
W !,"individual retirement accounts, etc.)",?91,"| $ ",$P(@EASD@("2E1"),U),?110,"| $ ",$P(@EASD@("2E1"),U,2)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"2. Market Value Of Land And Buildings MINUS Mortgages And Liens. Do NOT COUNT YOUR"
W !,"PRIMARY HOME. Include value of farm, ranch, or business assets.",?91,"| $ ",$P(@EASD@("2E2"),U),?110,"| $ ",$P(@EASD@("2E2"),U,2)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"3. Stocks And Bonds AND Value Of Other Property or Assets (art, rare coins, etc.) MINUS"
W !,"The Amount You Owe On These Items. Exclude household effects and family vehicles.",?91,"| $ ",$P(@EASD@("2E3"),U),?110,"| $ ",$P(@EASD@("2E3"),U,2)
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HEASEZPF2 6545 printed Nov 22, 2024@17:05 Page 2
EASEZPF2 ;ALB/SCK - Print 1010EZ Enrollment Form Cont., Page 2 ; 10/19/2000
+1 ;;1.0;ENROLLMENT APPLICATION SYSTEM;;Mar 15, 2001
+2 ;
EN(EALNE,EAINFO) ; Main entry point
+1 ; Input
+2 ; EALNE - Array of line formats for output
+3 ; EAINFO - Application Data array, see SETUP^EASEZPF
+4 ;
+5 NEW EASD
+6 ;
+7 DO HDR^EASEZPF(.EALNE,.EAINFO)
+8 WRITE !,?50,"SECTION II - FINANCIAL ASSESSMENT",!,EALNE("DD")
+9 ;
+10 SET EASD="^TMP(""EASEZ"",$J,2)"
+11 ;
+12 DO DEP
+13 DO FIN
+14 DO INC
+15 DO EXP
+16 DO NET
+17 ;
+18 DO FT^EASEZPF(.EALNE,.EAINFO)
+19 QUIT
+20 ;
DEP ; Print out VA 10-10EZ Section IIA, Dependent Information
+1 WRITE !,?52,"IIA - DEPENDENT INFORMATION",!,EALNE("D")
+2 WRITE !,"1. Spouse's Name ",@EASD@(1),?65,"|2. Child's Name ",@EASD@(2)
+3 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+4 ;
+5 WRITE !,"3. Spouse's Social Security Number ",$PIECE(@EASD@(3),U),?50,"|4. Spouse's Date Of Birth ",@EASD@(4),?90,"|5. Child's Date Of Birth ",@EASD@(5)
+6 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+7 ;
+8 WRITE !,"6. Spouse's Address",?65,"|7. Child's Social Security Number"
+9 WRITE !?1,$PIECE(@EASD@(6),U),?65,"| ",@EASD@(7)
+10 WRITE !?1,$PIECE(@EASD@(6),U,2),?65,"|"
+11 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+12 ;
+13 WRITE !,"8. Spouse's Telephone Number ",@EASD@(8),?65,"|9. Child's Relationship To You ",@EASD@(9)
+14 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+15 ;
+16 WRITE !,"10. Date of Marriage ",@EASD@(10),?65,"|11. Date Child Became Your Dependent ",@EASD@(11)
+17 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+18 ;
+19 WRITE !,"12. If Your Spouse or Dependent Child Did Not Live With You Last",?65,"|13. Expenses Paid By YOUR Dependent Child for College, Vocational"
+20 WRITE !,"Year, Enter the Amount you Contributed To Their Support",?65,"|Rehabilitation or Training (tuition, books, materials, etc.)"
+21 ;
+22 WRITE !?4,"Spouse $ ",$PIECE(@EASD@(12),U),?26,"Child $ ",$PIECE(@EASD@(12),U,2),?65,"| $ ",@EASD@(13)
+23 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+24 ;
+25 WRITE !,"14. Was Child Permanently And Totally Disabled Before",?65,"|15. If Child is Between 18 and 23 Years Of Age, Did Child"
+26 WRITE !,"The Age Of 18? ",@EASD@(14),?65,"| Attend School Last Calendar Year? ",@EASD@(15)
+27 QUIT
+28 ;
FIN ; Print out VA 10-10EZ Section IIB, Financial Disclosure information
+1 WRITE !,EALNE("DD")
+2 WRITE !,?50,"IIB - FINANCIAL DISCLOSURE"
+3 WRITE !,"You are not required to provide the financial information in this Section. However, current law may require VA to consider your"
+4 WRITE !,"household financial situation to determine your eligibility for enrollment and/or cost-free care of your nonservice-connected"
+5 WRITE !,"(NSC) conditions. If you are 0% SC noncompensable or NSC (and are not an Ex-POW, WWI veteran or VA pensioner) and your"
+6 WRITE !,"annual household income (or combined income net worth) exceeds the established threshold, you must agree to pay VA co-payments"
+7 WRITE !,"for care of your NSC conditions to be eligible for enrollment. See Section III - Consent and Signature"
+8 ;
+9 SET (EAY,EAN)="___"
+10 if EAINFO("DISC")="YES"
SET EAY=" X "
+11 if EAINFO("DISC")="NO"
SET EAN=" X "
+12 ;
+13 WRITE !!?4,EAY," YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO HAVE ELIGIBILITY FOR CARE DETERMINED. Complete all"
+14 WRITE !?8,"sections below that apply to you with last calendar year's information. Sign and date the application."
+15 WRITE !?4,EAN," NO, I DO NOT WISH TO PROVIDE MY DETAILED FINANCIAL INFORMATION. I understand I will be assigned the appropriate enrollment"
+16 WRITE !?8,"priority based on nondisclosure of my financial information. By checking NO and signing below, I am agreeing to pay the"
+17 WRITE !?8,"applicable VA co-payment. Sign and date the application."
+18 QUIT
+19 ;
INC ; Print out VA 10-10EZ Section IIC, Gross Annual Income information
+1 WRITE !,EALNE("DD")
+2 WRITE !?17,"IIC - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN"
+3 ;
+4 WRITE !?73,"| VETERAN",?90,"| SPOUSE",?110,"| CHILDREN"
+5 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+6 ;
+7 WRITE !,"1. What Was Your Gross Annual Income From Employment (wages, bonuses,"
+8 WRITE !,"tips, etc), As Well as Income From Your Farm, Ranch, Property or Business",?73,"| $ "
+9 WRITE $PIECE(@EASD@("2C1"),U),?90,"| $ ",$PIECE(@EASD@("2C1"),U,2),?110,"| $ ",$PIECE(@EASD@("2C1"),U,3)
+10 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+11 ;
+12 WRITE !,"2. List Other Income Amounts (Social Security, compensation, pension,"
+13 WRITE !,"interest, dividends) Exclude Welfare.",?73,"| $ "
+14 WRITE $PIECE(@EASD@("2C2"),U),?90,"| $ ",$PIECE(@EASD@("2C2"),U,2),?110,"| $ ",$PIECE(@EASD@("2C2"),U,3)
+15 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+16 ;
+17 WRITE !,"3. Was Income From Your Farm, Ranch, Property or Business (if yes, refer to page 2, Section IIC of the instructions.) ",@EASD@("2C3")
+18 ;
+19 QUIT
+20 ;
EXP ; Print out VA 10-10EZ Section IID, Deductible Expense Information
+1 WRITE !,EALNE("DD")
+2 WRITE !?50,"IID - DEDUCTIBLE EXPENSES"
+3 WRITE !,"1. Non-Reimbursed Medical Expenses Paid By You or Your Spouse (payments for doctors, dentists, drugs,"
+4 WRITE !,"Medicare, health insurance, hospital and nursing home)",?110,"| $ ",@EASD@("2D1")
+5 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+6 ;
+7 WRITE !,"2. Amount You Paid Last Calendar Year For Funeral And Burial Expenses For Deceased Spouse or Dependent"
+8 WRITE !,"Child (also enter spouse or child's information in Section IIA)",?110,"| $ ",@EASD@("2D2")
+9 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+10 ;
+11 WRITE !,"3. Amount You Paid Last Calendar Year For YOUR College or Vocational Educational Expenses (tutition, books,"
+12 WRITE !,"fees, materials, etc.) Do Not List Your Dependent's Educational Expenses.",?110,"| $ ",@EASD@("2D3")
+13 ;
+14 QUIT
NET ; Print out VA 10-10EZ Section IIE, Net Worth Information
+1 WRITE !,EALNE("DD")
+2 WRITE !?50,"IIE - NET WORTH"
+3 WRITE !?91,"| VETERAN",?110,"| SPOUSE"
+4 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+5 ;
+6 WRITE !,"1. Cash, Amount In Bank Accounts (checking and savings accounts, certificates of deposit,"
+7 WRITE !,"individual retirement accounts, etc.)",?91,"| $ ",$PIECE(@EASD@("2E1"),U),?110,"| $ ",$PIECE(@EASD@("2E1"),U,2)
+8 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+9 ;
+10 WRITE !,"2. Market Value Of Land And Buildings MINUS Mortgages And Liens. Do NOT COUNT YOUR"
+11 WRITE !,"PRIMARY HOME. Include value of farm, ranch, or business assets.",?91,"| $ ",$PIECE(@EASD@("2E2"),U),?110,"| $ ",$PIECE(@EASD@("2E2"),U,2)
+12 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+13 ;
+14 WRITE !,"3. Stocks And Bonds AND Value Of Other Property or Assets (art, rare coins, etc.) MINUS"
+15 WRITE !,"The Amount You Owe On These Items. Exclude household effects and family vehicles.",?91,"| $ ",$PIECE(@EASD@("2E3"),U),?110,"| $ ",$PIECE(@EASD@("2E3"),U,2)
+16 QUIT
