Submit the completed VA Request for Hardship Determination form to the appropriate VA office. You can mail the form to the local VA medical center or submit it in person. For more convenience, use the online submission option available on the VA website. Ensure all necessary documentation is attached to avoid any delays. For more specific submission guidance, consult the local VA office contact details provided on their official website.

The current form is valid until 06/30/2024. Ensure to submit any hardship requests before this expiration date.

The VA Request for Hardship Determination form serves to assist veterans who are experiencing financial difficulties. By filling out this form, veterans can apply for exemptions from payment of hospital and medical care copays due to reduced income or increased deductible expenses. The form ensures that eligible veterans are enrolled in Priority Group 5, providing vital healthcare benefits during times of financial hardship.

• 1. Veteran's Name: Enter the veteran's full name including last, first, and middle names.
• 2. Social Security Number: Enter the veteran's social security number.
• 3. Permanent Address: Provide the veteran's street address, including city, state, ZIP code, and county.
• 4. Telephone Numbers: Provide the veteran's home and cellular telephone numbers, including area codes.
• 5. Reason for Hardship Request: Check the appropriate boxes that describe the reason for the hardship request and provide additional explanation if needed.
• 6. Household Income: Include gross income from employment, net income from farm or ranch, and other income amounts for the veteran, spouse, and children.
• 7. Deductible Expenses: List non-reimbursed medical expenses, funeral and burial expenses, and expenses for the veteran's education.
• 8. Signature and Date: The veteran must sign and date the form using the MM/DD/YYYY format.

Failure to submit this form can lead to the veteran not receiving the necessary financial relief.

• Delay in Benefits: A delayed submission could result in a delay in receiving exemptions from copays.
• Denial of Request: Not providing the form may result in a denial of the hardship request.

• 1. Reduction in Income: If you have a reduction in household income, use this form to apply for financial relief.
• 2. High Medical Expenses: Use this form if you have paid high out-of-pocket medical expenses.
• 3. Increased Dependents: Apply for financial relief using this form if you have an increase in the number of dependents.
• 4. Move to Higher Living Cost Area: Moving to a higher cost of living area can be grounds for requesting financial relief using this form.