- 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 worker completes an original and one copy of Form 1240-TSI.
The eligibility worker mails the original to the VA regional office and keeps the duplicate in the case folder until a reply is received. The eligibility worker may destroy the duplicate after a reply is received from VA.
Original Form 1240-TSI 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 worker 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 worker enters the date the Form 1240-TSI 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 worker's complete mailing address.
Signature – Veteran – Date — The veteran signs on Page 1, and dates the signature, thereby authorizing VA to disclose information to HHSC.
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 worker 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.
Tax Sensitive Information — If the request is based on information obtained on an RG-101, check the "Yes" box. Do not include a copy of the RG-101 with the request. If the request is not based on information obtained on an RG-101, check the "No" box.
The worker signs on Page 1, and enters the date and local office telephone number. The worker enters the "Return Form To:" information on Page 2. The VA representative completes all other items on Page 2.