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- To request the amount of compensation, pension, or other benefits (e.g., aid and attendance, housebound allowance, etc.) paid to a veteran or a veteran's dependents/survivors.
- To request information about whether or not an institutionalized claimant's VA Improved Pension benefits will be capped at $90, and, if so, the first month that the claimant will receive a $90 check.
- To request information concerning whether or not a claimant's benefits have been augmented for a dependent, and if so, the amount by which they have been augmented.
- To request information concerning whether or not a claimant is receiving full payment, and, if not, why (e.g., recoupment suspension).
- To request information concerning whether or not the claimant's benefits have been adjusted for out-of-pocket medical expenses, and, if so, by how much.
- To serve as the veteran's authorization for the VA to release information.
Number of Copies
The eligibility specialist completes an original and one copy of Form H1240.
The eligibility specialist mails the original to the VA regional office and keeps the duplicate in the case folder until a reply is received. The eligibility specialist may destroy the duplicate after a reply is received from VA.
Form H1240 is kept in the case folder for three years after the client's eligibility is denied.
Name of Veteran— Enter the full name of the veteran.
C or XC No.— Enter the C or XC number, if available. The C or XC number is more important to VA than the exact name of the veteran. If a number is not available, however, the VA can identify the claim if the eligibility specialist can provide the following information about the veteran: address, date of birth, race, period of service, and serial number. The VA can give faster service if a C number is on the form.
Date— The eligibility specialist enters the date the Form H1240 is sent to the VA.
To: Bureau of Veterans Affairs Regional Office— Enter the complete mailing address of the VA Regional Office from which information is being requested.
Return To:— Enter the eligibility specialist's complete mailing address.
Signature — Veteran — Date— The veteran signs his name and dates the signature, thereby authorizing VA to disclose information to DHS.
Please furnish the following information on benefits received by:
Name— Enter the name of the applicant/recipient.
Payee, if different— If a payee receives the VA check on behalf of the claimant (applicant/recipient), enter the payee's name.
Claimant institutionalized?— The eligibility specialist checks the appropriate box to indicate whether or not the client is institutionalized. This entry will assist the Bureau of Veterans Affairs in determining whether or not VA Improved Pension benefits will be capped at $90.
Address— Enter the address of the claimant/payee.
Comments:— Enter any comments that may assist the VA in identifying the claimant or in providing information.
Signature — Specialist — Telephone No.— The eligibility specialist signs the form and enters his telephone number (including area code).
To Be Completed By VA:
All items are self-explanatory.
Signature — VA Official — Telephone No. — Date— The VA official signs the form, enters his telephone number, and dates the signature.