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VA FORM MAR 2015 10-10HS Page 1 HARDSHIP DETERMINATION to be completed by VA Hardship Granted circle one YES Hardship is granted Note The exemption is effective from the date the Veteran submitted the request until the last day of the calendar year in which the request was made. Request for Hardship Determination The Request for Hardship Determination form is used to determine whether the veteran s projected income for the current year will be substantially below the VA means test threshold due to a loss of income or increase in allowable deductible expenses. NO State reason not granted in comments. Date Veteran s electronic record updated in VA s information system VHA Staff Signature Date COMMENTS Document and/or attach any pertinent information impacting on the final decision. VETERAN NOTIFICATION Date Veteran Notified If hardship not granted provide Veteran with VA Form 4107VHA YOUR RIGHTS TO APPEAL OUR DECISION. PAGE 2. Veterans determined to have a financial hardship will be exempt from payment of hospital and medical care copays and qualify for enrollment in Priority Group 5 unless otherwise eligible for enrollment in a higher priority from the date of request through the last day of the same calendar year. GENERAL INFORMATION 2. SOCIAL SECURITY NUMBER 1. VETERAN S NAME Last First Middle Name 3. PERMANENT ADDRESS Street 3D. COUNTY 3A. CITY 3B. STATE 3E* HOME TELEPHONE NUMBER Include area code 3C. ZIP CODE 9 digits 3F* CELLULAR TELEPHONE NUMBER Include area code REASON/CIRCUMSTANCE FOR HARDSHIP REQUEST Check all that apply and add explanation as needed below Reduction of household income Paid out of pocket medical expenses Moved to a higher cost of living area Other - explain below Increase in number of dependents Provide explanation as needed and attach documentation supporting your request. PROJECTED HOUSEHOLD INCOME AND DEDUCTIBLE EXPENSES FOR THE CURRENT CALENDAR YEAR Veteran 1. HOUSEHOLD INCOME Includes gross income from employment net income from farm or ranch and other income amounts. 2. DEDUCTIBLE EXPENSES Includes non-reimbursed medical expenses paid by you or your spouse funeral and burial expenses and expenses for the veteran s education* Spouse Children PAPERWORK REDUCTION ACT AND 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 15 minutes. This includes the time it will take to read instructions gather the necessary facts and fill out the form* Privacy Act Information VA is asking you to provide the information on this form under 38 U*S*C. Sections 1705 1710 1712 and 1722 in order for VA to determine your eligibility for medical benefits.