FORM 4. DECLARATION OF UNREIMBURSED MEDICAL

HEAD OF HOUSEHOLD NAME

SOCIAL SECURITY NUMBER (last 4 digits)

FORM 4. DECLARATION OF UNREIMBURSED MEDICAL & PHARMACY EXPENSES

Is Your Household Eligible for a Medical Expense Deduction?

1. Do you have any unreimbursed pharmacy expenses? □ Yes □ No

2. Do you pay a Medicare premium or pay for medical insurance? □ Yes □ No

3. Is any household member currently paying off past medical bills? □ Yes □ No

4. Is there an anticipated medical expense during the next 12 months?□ Yes □ No

If you answered yes to any of the questions above, please complete the box below:

Name of

Household Member

Eligible Expense

(pharmacy, insurance

premiums, dental, hearing

aid, eyeglasses, medical

equipment)

Amount Due, Paid in the

Past, or Expected in the

Next 12 Months* (Submit

proof of payment or

invoice)

Expense Date or

Payment

Frequency

(monthly,

annually, etc.)

Name and Phone

Number of Institution

Providing Service

*If copies of cancelled checks, receipts, or statements from an insurance company are not available, you may

submit a statement from your doctor, pharmacist, or other medical-related service provider specifying the nature

and amount of expenses expected in the next 12 months. Only the portion of the total medical and pharmacy

expenses and disability expenses (Form 5) that exceeds 3% of the household annual income is an allowable

deduction.

If the Head of Household, co-head, or spouse is disabled, and/or 62 years of age or older and has unreimbursed

(not already paid for by someone other than yourself) medical or pharmacy expenses, please complete this form

for each household member with medical or pharmacy expenses. You must submit verification of all unreimbursed

medical and pharmacy expenses incurred during the last 12 months if they are expected to be an expense in the

upcoming year. This includes copies of cancelled checks, receipts, or statements from an insurance company.

Please submit a pharmacy printout for any unreimbursed prescription payments you have made in the past 12

months.

TO BE COMPLETED AND SIGNED BY THE HEAD OF HOUSEHOLD

I certify that the above information is accurate and understand that providing false statements to a government agency is

punishable under federal law and may result in loss of HRA HOME TBRA benefits.

_______________________________________________ _______/________/_______

SIGNATURE OF HEAD OF HOUSEHOLD DATE