80 lines
3.9 KiB
Mathematica
80 lines
3.9 KiB
Mathematica
EASEZRP3 ;ALB/AMA - Print 1010EZR, Cont.
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;;1.0;ENROLLMENT APPLICATION SYSTEM;**57**;Mar 15, 2001
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Q
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;
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EN(EALNE,EAINFO) ; Entry point to print Page 3, called from EN^EASEZRPF
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; Input
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; EALNE - Array of line formats for output
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; EAINFO - Application Data array, see SETUP^EASEZRPF
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N EASIGN,EASD
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;
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I $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]"" D
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. S EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
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S EASIGN=$G(EASIGN)
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;
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D HDR^EASEZRPF(.EALNE,.EAINFO)
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S EASD=$NA(^TMP("EASEZR",$J,2))
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;
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D NET
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D CON
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D AOB
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D FT^EASEZRPF(.EALNE,.EAINFO)
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;
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Q
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;
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NET ; Print SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH
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;
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W !?18,"SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH (Use a separate sheet for additional dependents)"
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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;
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W !?78,"|",?84,"VETERAN",?96,"|",?102,"SPOUSE",?114,"|",?120,"CHILD 1"
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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;
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W !,"1. CASH, AMOUNT IN BANK ACCOUNTS (e.g., checking and savings accounts,",?78,"| $ ",$P(@EASD@("2E1"),U),?96,"| $ ",$P(@EASD@("2E1"),U,2),?114,"| $ ",$P(@EASD@("2E1"),U,3)
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W !,"certificates of deposit, individual retirement accounts, stocks and bonds)",?78,"|",?96,"|",?114,"|"
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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;
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W !,"2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS (e.g., second",?78,"| $ ",$P(@EASD@("2E2"),U),?96,"| $ ",$P(@EASD@("2E2"),U,2),?114,"| $ ",$P(@EASD@("2E2"),U,3)
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W !,"homes and non-income-producing property. Do not include your primary home.)",?78,"|",?96,"|",?114,"|"
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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;
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W !,"3. VALUE OF OTHER PROPERTY OR ASSETS (e.g., art, rare coins, collectibles)",?78,"| $ ",$P(@EASD@("2E3"),U),?96,"| $ ",$P(@EASD@("2E3"),U,2),?114,"| $ ",$P(@EASD@("2E3"),U,3)
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W !,"MINUS THE AMOUNT YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH, OR",?78,"|",?96,"|",?114,"|"
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W !,"BUSINESS ASSETS. Exclude household effects and family vehicles.",?78,"|",?96,"|",?114,"|"
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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Q
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;
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CON ; Print SECTION X - CONSENT TO COPAYMENTS
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;
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W !?49,"SECTION X - CONSENT TO COPAYMENTS"
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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;
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W !,"If you are a 0% service-connected veteran and do not receive VA monetary benefits or a nonservice-connected veteran (and you are"
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W !,"not an Ex-POW, Purple Heart Recipient, WWI veteran or VA pensioner) and your household income (or combined income and net worth)"
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W !,"exceeds the established threshold, this application will be considered for enrollment, but only if you agree to pay VA copayments"
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W !,"for treatment of your nonservice-connected conditions. If you are such a veteran, by signing this application you are agreeing"
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W !,"to pay the applicable VA copayment as required by law.",!
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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Q
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;
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AOB ; Print SECTION XI - ASSIGNMENT OF BENEFITS
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;
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W !?48,"SECTION XI - ASSIGNMENT OF BENEFITS"
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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;
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W !,"I understand that pursuant to 38 U.S.C. Section 1729, VA is authorized to recover or collect from my health plan (HP) for the"
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W !,"reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment"
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W !,"directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for"
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W !,"payment of the charges for my medical care, including benefits otherwise payable to me or my spouse.",!
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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;
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W !?11,"ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS ON WHO CAN SIGN ON BEHALF OF THE VETERAN.",!
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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;
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W !,"SIGNATURE OF APPLICANT",?90,"| DATE (mm/dd/yyyy)"
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I $G(EASIGN)]"" W !,"SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?90,"| ",EASIGN,!?90,"|"
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E W !?90,"|",!?90,"|"
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W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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Q
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