Create va form in minutes using a fillable PDF editor. Fill va form va instantly, download blank or editable online. Sign , fax and printable from PC, iPad, tablet or mobile. No software. Try Now!. VA Form , Financial Status Report, is used to determine eligibility for waiver of collection, for the acceptance of a compromise offer or for a payment plan.

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Section I is related to your personal data. Box 3 asks you to specify the reason why the form is being filled out. If your gross household income has decreased, you may be eligible for enrollment in a higher Priority Group which may qualify you for copayment exemption.

Office of Veteran Affairs

You also have the right to request a compromise. Why is the VA referring your delinquent debt to the Department of the Treasury?

Section V is for your assets, including your cash in the bank and on hand, your vehicles, savings bonds, and any real estate you own. Generally speaking, this form is filled out by the claimant. For the ca part, this form is used if a person is meant to repay the VA, but they do not have the financial capacity to do so.

To request a hardship determination, send a letter explaining any financial hardship these charges will cause you and a completed Request for Hardship Determination VA Form HS. Bureau, State Veterans Home – Pocatello. If vva fail to make a payment on your debt before it reaches one hundred twenty days delinquent, days from initial billing statement dateaccounts without VA benefits available for offset will automatically transfer to the Department of the Ba Cross-Servicing Program.


Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for rorm instructions. VA systems of records and alterations to the systems are published in the Federal Register. These cookies only collect personal data when you opt in to the PDF editor.

This piece of paperwork reflects your financial status.

Will you be able to continue receiving health care services if your bill is referred to Treasury? Each dependent receives an additional stipulation in order for the parents to best care for them. Any monthly VA benefits you receive should be added to your monthly income.

Veteran’s Copayment Responsibility for VA Health Care | Idaho Division of Veterans Services

You have the right to establish a monthly repayment plan at any time during your enrollment in VA health care if you cannot pay your debt in full. If the waiver is granted you will not be required to pay the amount waived.

Download the document to your desktop, forj or smartphone to be able to print it out in full.

Quarterly Financial Status Report Template. The form captures a zoomed-out look at their overall torm. EST, Monday through Friday to speak with a representative. Information about the overpayment claim itself will be filed with different forms, depending on the circumstances. The report will be just part of your application for a change to be made. What type of application are you filing?

You have the right to request a hearing in connection with your request for a waiver. Any information provided by you. In 24B, you should mark the amount you can reasonably pay toward your incurred debt on a monthly basis.


Just upload a 6555 to get started! Your balance is considered from if it remains unpaid after the balance due date on your initial billing statement, which is typically thirty 30 days after the statement date.

If you make a payment online it will be applied to any outstanding balance not at Treasury. Your health care services will continue without interruption regardless of whether your bill is referred to Treasury.

If your gross household income has decreased from the previous income year, you may be eligible for a Hardship Determination which provides future exemption from medical and hospital care copays for a determined period of time. Bureau, State Veterans Home – Boise. Our software makes quick work of file conversion from your PDF. Forn, the debt accrues because the claimant either accidentally or purposefully for information that would affect their benefits.

To pay a bill that has been referred to Treasury, contact Debt Management Services toll free at between 8: TOP has a tiered fee schedule based on the type of offset e. Indicate your proposed monthly payment amount in paragraph 1A. The claimant will need to 56555 information about their finances along with the finances of their spouse. Both the spouse and the claimant must sign the form to verify that all of the information is accurate.

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