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amponce/01-efsr-maximal.json

Last active July 24, 2023 20:40
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01-efsr-maximal.json
{
"view:combinedFinancialStatusReport": true,
"view:enhancedFinancialStatusReport": true,
"otherExpenses": [
{
"name": "Clothing",
"amount": "10"
},
{
"name": "Food",
"amount": "1000.54"
},
{
"name": "Veteran added",
"amount": "100"
}
],
"view:components": {
"view:assetInfo": {},
"view:recVehicleInfo": {},
"view:vehicleInfo": {},
"view:maritalStatus": {},
"view:veteranInfo": {},
"view:vaBenefitsOnFile": {}
},
"expenses": {
"expenseRecords": [
{
"name": "Rent",
"amount": "1200.53"
}
],
"creditCardBills": [
{
"purpose": "Credit card payment",
"creditorName": "",
"originalAmount": "",
"unpaidBalance": "300000",
"amountDueMonthly": "10000",
"dateStarted": "",
"amountPastDue": "7000"
}
]
},
"assets": {
"realEstateValue": "800000.81",
"otherAssets": [
{
"name": "Collectibles, or collection(s)",
"amount": "12344"
},
{
"name": "Antiques",
"amount": "44"
},
{
"name": "Fine art",
"amount": "122"
}
],
"cashInBank": "3000.45",
"cashOnHand": "10000.67",
"recVehicleAmount": "15000.23",
"usSavingsBonds": "25000.65",
"stocksAndOtherBonds": "50000.84",
"automobiles": [
{
"make": "Dodge",
"model": "RAM",
"year": "2020",
"resaleValue": "75000.45"
},
{
"make": "Dodge",
"model": "Charger",
"year": "2020",
"resaleValue": "40000.54"
}
],
"monetaryAssets": [
{
"name": "Cash",
"amount": "100"
},
{
"name": "Checking accounts",
"amount": "100"
},
{
"name": "Savings accounts",
"amount": "100"
},
{
"name": "U.S. Savings Bonds",
"amount": "100"
},
{
"name": "Retirement accounts (401k, IRAs, 403b, TSP)",
"amount": "100"
},
{
"name": "Other stocks and bonds (not in your retirement accounts)",
"amount": "100"
},
{
"name": "Pension",
"amount": "100"
},
{
"name": "Cryptocurrency",
"amount": "100"
}
]
},
"additionalIncome": {
"spouse": {
"spAddlIncome": [
{
"name": "Child care income",
"amount": "800.54"
},
{
"name": "Alimony payment",
"amount": "1000.23"
}
]
},
"addlIncRecords": [
{
"name": "Social Security",
"amount": "150.67"
},
{
"name": "Alimony",
"amount": "210.43"
}
]
},
"socialSecurity": {
"spouse": {
"socialSecAmt": "1400.45"
},
"socialSecAmt": "1200.65"
},
"benefits": {
"spouseBenefits": {
"compensationAndPension": "1000.09",
"education": "500.46"
}
},
"additionalData": {
"bankruptcy": {
"dateDischarged": "2004-10-22",
"courtLocation": "Tampa, FL",
"docketNumber": "123456"
},
"additionalComments": "Supporting personal statement..."
},
"questions": {
"hasBeenAdjudicatedBankrupt": true,
"hasCreditCardBills": true,
"hasOtherExpenses": true,
"hasRepayments": true,
"hasUtilities": true,
"hasRecreationalVehicle": true,
"hasVehicle": true,
"hasRealEstate": true,
"hasDependents": "2",
"spouseHasAdditionalIncome": true,
"spouseHasSocialSecurity": true,
"spouseHasBenefits": true,
"spouseIsEmployed": true,
"isMarried": true,
"hasAdditionalIncome": true,
"hasSocialSecurity": true,
"vetIsEmployed": true
},
"installmentContracts": [
{
"purpose": "Credit card payments",
"creditorName": "Creditor One",
"originalAmount": "50000.54",
"unpaidBalance": "15000.56",
"amountDueMonthly": "800.10",
"dateStarted": "2017-03-XX",
"amountPastDue": "125.43"
},
{
"purpose": "Car payment/lease",
"creditorName": "Creditor Two",
"originalAmount": "100000.43",
"unpaidBalance": "50000.26",
"amountDueMonthly": "1200.54",
"dateStarted": "2019-05-XX",
"amountPastDue": "0"
}
],
"utilityRecords": [
{
"name": "Electricity",
"amount": "402.35"
},
{
"name": "Gas",
"amount": "85.16"
},
{
"name": "Cable",
"amount": "175.47"
}
],
"personalData": {
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{
"dependentAge": "12"
},
{
"dependentAge": "17"
}
],
"employmentHistory": {
"spouse": {
"spEmploymentRecords": [
{
"type": "Full time",
"from": "2018-6-XX",
"to": "",
"isCurrent": true,
"employerName": "Spouse Current",
"grossMonthlyIncome": "100",
"deductions": [
{
"name": "State tax",
"amount": "10"
}
]
},
{
"type": "Full time",
"from": "2015-3-XX",
"to": "2018-6-XX",
"employerName": "Spouse Previous",
"isCurrent": false
}
]
},
"veteran": {
"employmentRecords": [
{
"type": "Full time",
"from": "2021-01-XX",
"to": "",
"isCurrent": true,
"employerName": "Test",
"grossMonthlyIncome": "123",
"deductions": [
{
"name": "State tax",
"amount": "1"
}
]
},
{
"type": "Full time",
"from": "2021-01-XX",
"to": "2021-12-XX",
"isCurrent": false,
"employerName": "I quit"
}
]}
},
"spouseFullName": {
"first": "Angela",
"last": "Mitchell"
},
"address": {
"livesOnMilitaryBaseInfo": {},
"country": "USA",
"street": "123 Fake Street",
"city": "Tampa",
"state": "FL",
"postalCode": "33543"
},
"telephoneNumber": "4445551212",
"emailAddress": "[email protected]",
"veteranContactInformation": {
"email": "[email protected]",
"address": {
"addressLine1": "1200 Park Ave",
"addressLine2": "c/o Pixar",
"addressLine3": null,
"addressPou": "CORRESPONDENCE",
"addressType": "DOMESTIC",
"city": "Emeryville",
"countryName": "United States",
"countryCodeIso2": "US",
"countryCodeIso3": "USA",
"countryCodeFips": null,
"countyCode": null,
"countyName": null,
"createdAt": "2020-05-30T03:57:20.000+00:00",
"effectiveEndDate": null,
"effectiveStartDate": "2020-07-10T20:10:45.000+00:00",
"id": 173917,
"internationalPostalCode": null,
"province": null,
"sourceDate": "2020-07-10T20:10:45.000+00:00",
"sourceSystemUser": null,
"stateCode": "CA",
"transactionId": "7139aa82-fd06-45ea-a217-9654869924bd",
"updatedAt": "2020-07-10T20:10:46.000+00:00",
"validationKey": null,
"vet360Id": "1273780",
"zipCode": "94608",
"zipCodeSuffix": null
},
"mobilePhone": {
"areaCode": "510",
"countryCode": "1",
"createdAt": "2020-06-12T16:56:37.000+00:00",
"extension": "",
"effectiveEndDate": null,
"effectiveStartDate": "2020-07-14T19:07:45.000+00:00",
"id": 146766,
"isInternational": false,
"isTextable": null,
"isTextPermitted": null,
"isTty": null,
"isVoicemailable": null,
"phoneNumber": "9224444",
"phoneType": "HOME",
"sourceDate": "2020-07-14T19:07:45.000+00:00",
"sourceSystemUser": null,
"transactionId": "92c49d39-22b2-4bd6-92b4-0b7e7c63c6a9",
"updatedAt": "2020-07-14T19:07:46.000+00:00",
"vet360Id": "1273780"
}
},
"veteranFullName": {
"first": "Greg",
"last": "Anderson",
"middle": "A"
},
"dateOfBirth": "1933-04-05"
},
"personalIdentification": {
"ssn": "1234",
"fileNumber": "5678"
},
"selectedDebts": [],
"selectedDebtsAndCopays": [
{
"fileNumber": "796121200",
"payeeNumber": "00",
"personEntitled": "AJHONS",
"deductionCode": "30",
"benefitType": "Comp & Pen",
"diaryCode": "080",
"diaryCodeDescription": "Referred to the Department of the Treasury",
"amountOverpaid": 0,
"amountWithheld": 0,
"originalAr": 136.24,
"currentAr": 100,
"debtHistory": [
{
"date": "02/25/2009",
"letterCode": "914",
"description": "Paid In Full - Account balance cleared via offset, not including TOP."
},
{
"date": "02/07/2009",
"letterCode": "905",
"description": "Administrative Write Off"
},
{
"date": "12/03/2008",
"letterCode": "487",
"description": "Death Case Pending Action"
}
],
"id": 0,
"debtType": "DEBT",
"resolutionOption": "waiver",
"resolutionComment": "",
"resolutionWaiverCheck": true
},
{
"fileNumber": "796121200",
"payeeNumber": "00",
"personEntitled": "AJOHNS",
"deductionCode": "74",
"benefitType": "CH33 Student Tuition EDU",
"diaryCode": "117",
"diaryCodeDescription": "Pending payment",
"amountOverpaid": 0,
"amountWithheld": 475,
"originalAr": 2210.9,
"currentAr": 1000,
"debtHistory": [
{
"date": "04/01/2017",
"letterCode": 608,
"description": "Full C&P Benefit Offset Notifi"
},
{
"date": "11/18/2015",
"letterCode": 130,
"description": "Debt Increase - Due P"
},
{
"date": "04/08/2015",
"letterCode": 608,
"description": "Full C&P Benefit Offset Notifi"
},
{
"date": "03/26/2015",
"letterCode": 100,
"description": "First Demand Letter - Inactive Benefits - Due Process"
}
],
"id": 3,
"debtType": "DEBT",
"resolutionOption": "monthly",
"resolutionComment": "50.51"
},
{
"id": "f4385298-08a6-42f8-a86f-50e97033fb85",
"pSSeqNum": 506,
"pSTotSeqNum": 588,
"pSFacilityNum": "534",
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"pSStatementVal": "0000018255H",
"pSStatementDate": "11152019",
"pSStatementDateOutput": "11/15/2019",
"pSProcessDate": "11112019",
"pSProcessDateOutput": "11/11/2019",
"pHPatientLstNme": "JONES",
"pHPatientFstNme": "TRAVIS",
"pHPatientMidNme": "D",
"pHAddress1": "1885 SHORE DR S APT 327",
"pHAddress2": null,
"pHAddress3": null,
"pHCity": "SAVANNAH",
"pHState": "FL",
"pHZipCde": "314104413",
"pHZipCdeOutput": "31410-4413",
"pHCtryNme": null,
"pHAmtDue": 15,
"pHAmtDueOutput": "15.00  ",
"pHPrevBal": 135,
"pHPrevBalOutput": "135.00  ",
"pHTotCharges": 15,
"pHTotChargesOutput": "15.00  ",
"pHTotCredits": -135,
"pHTotCreditsOutput": "135.00- ",
"pHNewBalance": 15,
"pHNewBalanceOutput": "15.00  ",
"pHSpecialNotes": "To pay your statement online, go to www.pay.gov or call 1-888-827-4817.",
"pHroParaCdes": "304050556065708085",
"pHNumOfLines": 10,
"pHDfnNumber": 346310,
"pHCernerStatementNumber": 1005154223,
"pHCernerPatientId": "1005154223",
"pHCernerAccountNumber": "1005154223",
"pHIcnNumber": "1012845638V677813",
"pHAccountNumber": 0,
"pHLargeFontIndcator": 0,
"details": [
{
"pDDatePosted": "10072019",
"pDDatePostedOutput": "10/07/2019",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": -15,
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "534-K90HEWN"
},
{
"pDDatePosted": "10072019",
"pDDatePostedOutput": "10/07/2019",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": -15,
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "534-K90HEWN"
},
{
"pDDatePosted": "10072019",
"pDDatePostedOutput": "10/07/2019",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": -15,
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "534-K90HEWN"
},
{
"pDDatePosted": "10072019",
"pDDatePostedOutput": "10/07/2019",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": -15,
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "534-K90HEWN"
},
{
"pDDatePosted": "10072019",
"pDDatePostedOutput": "10/07/2019",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": -15,
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "534-K90HEWN"
},
{
"pDDatePosted": "10072019",
"pDDatePostedOutput": "10/07/2019",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": -15,
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "534-K90HEWN"
},
{
"pDDatePosted": "10072019",
"pDDatePostedOutput": "10/07/2019",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": -15,
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "534-K90HEWN"
},
{
"pDDatePosted": "10072019",
"pDDatePostedOutput": "10/07/2019",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": -15,
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "534-K90HEWN"
},
{
"pDDatePosted": "10072019",
"pDDatePostedOutput": "10/07/2019",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": -15,
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "534-K90HEWN"
},
{
"pDDatePosted": "10152019",
"pDDatePostedOutput": "10/15/2019",
"pDTransDesc": "OUTPATIENT CARE(NSC) VISIT DATE: 09/07/2018",
"pDTransDescOutput": "OUTPATIENT CARE VISIT DATE: 09/07/2018",
"pDTransAmt": 15,
"pDTransAmtOutput": "15.00  ",
"pDRefNo": "534-K009FK8"
}
],
"station": {
"facilitYNum": "534",
"visNNum": "07",
"facilitYDesc": "RALPH H. JOHNSON VA MEDICAL CENTER (534)",
"cyclENum": "012",
"remiTToFlag": "L",
"maiLInsertFlag": "0",
"staTAddress1": "ACCOUNTS RECEIVABLE (04AR)",
"staTAddress2": "109 BEE ST",
"staTAddress3": null,
"city": "CHARLESTON",
"state": "SC",
"ziPCde": "294015703",
"ziPCdeOutput": "29401-5703",
"baRCde": "*294015703090*",
"teLNumFlag": "P",
"teLNum": "1-866-258-2772",
"teLNum2": null,
"contacTInfo": null,
"dM2TelNum": null,
"contacTInfo2": null,
"toPTelNum": null,
"lbXFedexAddress1": null,
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"lbXFedexContact": null,
"lbXFedexContactTelNum": null,
"facilityName": "Bob Stump Department of Veterans Affairs Medical Center"
},
"debtType": "COPAY",
"resolutionOption": "compromise",
"resolutionComment": "10.51"
},
{
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"pSStatementVal": "0000040520F",
"pSStatementDate": "06052021",
"pSStatementDateOutput": "06/05/2021",
"pSProcessDate": "06092021",
"pSProcessDateOutput": "06/09/2021",
"pHPatientLstNme": "JONES",
"pHPatientFstNme": "TRAVIS",
"pHPatientMidNme": "D",
"pHAddress1": "1885 SHORE DR S APT 327",
"pHAddress2": null,
"pHAddress3": null,
"pHCity": "SOUTH PASADENA",
"pHState": "FL",
"pHZipCde": "337074743",
"pHZipCdeOutput": "33707-4743",
"pHCtryNme": "US",
"pHAmtDue": 46,
"pHAmtDueOutput": "46.00  ",
"pHPrevBal": 30,
"pHPrevBalOutput": "30.00  ",
"pHTotCharges": 46,
"pHTotChargesOutput": "46.00  ",
"pHTotCredits": -30,
"pHTotCreditsOutput": "30.00- ",
"pHNewBalance": 46,
"pHNewBalanceOutput": "46.00  ",
"pHSpecialNotes": null,
"pHroParaCdes": "254050556065708085",
"pHNumOfLines": 7,
"pHDfnNumber": 0,
"pHCernerStatementNumber": 1005154223,
"pHCernerPatientId": "1005154223",
"pHCernerAccountNumber": "1005154223",
"pHIcnNumber": "1012845638V677813",
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"details": [
{
"pDDatePosted": "03092020",
"pDDatePostedOutput": "03/09/2020",
"pDTransDesc": "OUTPATIENT CARE(NSC) VISIT DATE: 01/14/2020",
"pDTransDescOutput": "OUTPATIENT CARE VISIT DATE: 01/14/2020",
"pDTransAmt": 15,
"pDTransAmtOutput": "15.00  ",
"pDRefNo": "516-K00R4FL"
},
{
"pDDatePosted": "03092020",
"pDDatePostedOutput": "03/09/2020",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": -15,
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "516-K00R4FL"
},
{
"pDDatePosted": "03242020",
"pDDatePostedOutput": "03/24/2020",
"pDTransDesc": "COPAY RX:100020337B FD:01/23/2020",
"pDTransDescOutput": "COPAY RX#100020337B FILL DATE: 01/23/2020",
"pDTransAmt": 5,
"pDTransAmtOutput": "5.00  ",
"pDRefNo": "516-K00RSNZ"
},
{
"pDDatePosted": null,
"pDDatePostedOutput": "",
"pDTransDesc": "DRUG:LISINOPRIL 5MG TAB DAYS:30 QTY:30",
"pDTransDescOutput": "   DRUG:LISINOPRIL 5MG TAB DAYS:30 QTY:30",
"pDTransAmt": 0,
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": null,
"pDDatePostedOutput": "",
"pDTransDesc": "PHY:SANTOS,LOUISE CHG:$5.00",
"pDTransDescOutput": "   PHY:SANTOS,LOUISE CHG:$5.00",
"pDTransAmt": 0,
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": "03242020",
"pDDatePostedOutput": "03/24/2020",
"pDTransDesc": "RX CO-PAYMENT/NSC VET",
"pDTransDescOutput": "PAYMENT POSTED ON 03/24/2020",
"pDTransAmt": -5,
"pDTransAmtOutput": "5.00- ",
"pDRefNo": "516-K00RSNZ"
},
{
"pDDatePosted": "04032020",
"pDDatePostedOutput": "04/03/2020",
"pDTransDesc": "COPAY RX:100030241 FD:03/30/2020",
"pDTransDescOutput": "COPAY RX#100030241 FILL DATE: 03/30/2020",
"pDTransAmt": 15,
"pDTransAmtOutput": "15.00  ",
"pDRefNo": "516-K00S829"
},
{
"pDDatePosted": null,
"pDDatePostedOutput": "",
"pDTransDesc": "DRUG:ATENOLOL 25MG TAB DAYS:90 QTY:90",
"pDTransDescOutput": "   DRUG:ATENOLOL 25MG TAB DAYS:90 QTY:90",
"pDTransAmt": 0,
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": null,
"pDDatePostedOutput": "",
"pDTransDesc": "PHY:GUTHRIE,BROOKE L CHG:$15.00",
"pDTransDescOutput": "   PHY:GUTHRIE,BROOKE L CHG:$15.00",
"pDTransAmt": 0,
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": "04272020",
"pDDatePostedOutput": "04/27/2020",
"pDTransDesc": "COPAY RX:100020336 FD:04/23/2020",
"pDTransDescOutput": "COPAY RX#100020336 FILL DATE: 04/23/2020",
"pDTransAmt": 15,
"pDTransAmtOutput": "15.00  ",
"pDRefNo": "516-K00SZBK"
},
{
"pDDatePosted": null,
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"pDTransDesc": "DRUG:AMLODIPINE BESYLATE 10MG TAB DAYS:90",
"pDTransDescOutput": "   DRUG:AMLODIPINE BESYLATE 10MG TAB DAYS:90",
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"pDRefNo": null
},
{
"pDDatePosted": null,
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"pDTransDesc": "QTY:90 PHY:GUTHRIE,BROOKE L CHG:$15.00",
"pDTransDescOutput": "   QTY:90 PHY:GUTHRIE,BROOKE L CHG:$15.00",
"pDTransAmt": 0,
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": "04282020",
"pDDatePostedOutput": "04/28/2020",
"pDTransDesc": "COPAY RX:100011847 FD:04/23/2020",
"pDTransDescOutput": "COPAY RX#100011847 FILL DATE: 04/23/2020",
"pDTransAmt": 8,
"pDTransAmtOutput": "8.00  ",
"pDRefNo": "516-K00SZBK"
},
{
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"pDTransDesc": "DRUG:MICONAZOLE NITRATE 2% TOP TINCTURE DAYS:30",
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"pDDatePosted": null,
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},
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"visNNum": "22",
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},
"debtType": "COPAY",
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}
],
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"debtHistory": [
{
"date": ""
}
],
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},
"financialOverview": {},
"availableOptions": {},
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{
"veteranOrSpouse": "VETERAN",
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"education": "50"
}
]
}
Raw
02-submissionObj.json
{
"personalIdentification": {
"ssn": "1234",
"fileNumber": "5678",
"fsrReason": "Waiver, Extended monthly payments, Compromise"
},
"personalData": {
"veteranFullName": {
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"middle": "A",
"last": "Anderson"
},
"address": {
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"addresslineTwo": "c/o Pixar",
"addresslineThree": "",
"city": "Emeryville",
"stateOrProvince": "CA",
"zipOrPostalCode": "94608",
"countryName": "US"
},
"telephoneNumber": "(510) 922-4444",
"dateOfBirth": "04/05/1933",
"married": true,
"spouseFullName": {
"first": "Angela",
"middle": "",
"last": "Mitchell"
},
"agesOfOtherDependents": [
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"17"
],
"employmentHistory": [
{
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"occupationName": "Full time",
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"to": "",
"present": true,
"employerName": "Test",
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"city": "",
"stateOrProvince": "",
"zipOrPostalCode": "",
"countryName": ""
}
},
{
"veteranOrSpouse": "VETERAN",
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"from": "01/2021",
"to": "12/2021",
"present": false,
"employerName": "I quit",
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}
},
{
"veteranOrSpouse": "SPOUSE",
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}
},
{
"veteranOrSpouse": "SPOUSE",
"occupationName": "Full time",
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"present": false,
"employerName": "Spouse Previous",
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}
}
]
},
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},
{
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},
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},
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}
],
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"otherLivingExpenses": {
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},
"expensesInstallmentContractsAndOtherDebts": "12000.64",
"totalMonthlyExpenses": "14974.69"
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"pDDatePosted": "09222020",
"pDDatePostedOutput": "09/22/2020",
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"pDTransDescOutput": "   COMMENT: K00X41A PD $50.00 DOS 082020",
"pDTransAmt": "0.00",
"pDTransAmtOutput": ".00  ",
"pDRefNo": "516-K00XUY2"
},
{
"pDDatePosted": "10072020",
"pDDatePostedOutput": "10/07/2020",
"pDTransDesc": "COPAY RX:100030241 FD:10/05/2020",
"pDTransDescOutput": "COPAY RX#100030241 FILL DATE: 10/05/2020",
"pDTransAmt": "15.00",
"pDTransAmtOutput": "15.00  ",
"pDRefNo": "516-K10J56V"
},
{
"pDDatePosted": null,
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"pDTransDesc": "DRUG:ATENOLOL 25MG TAB DAYS:90 QTY:90",
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"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": null,
"pDDatePostedOutput": "",
"pDTransDesc": "PHY:GUTHRIE,BROOKE L CHG:$15.00",
"pDTransDescOutput": "   PHY:GUTHRIE,BROOKE L CHG:$15.00",
"pDTransAmt": "0.00",
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": "10292020",
"pDDatePostedOutput": "10/29/2020",
"pDTransDesc": "COPAY RX:100045030 FD:10/27/2020",
"pDTransDescOutput": "COPAY RX#100045030 FILL DATE: 10/27/2020",
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"pDTransAmtOutput": "24.00  ",
"pDRefNo": "516-K10J56V"
},
{
"pDDatePosted": null,
"pDDatePostedOutput": "",
"pDTransDesc": "DRUG:NIACIN (SLO-NIACIN) 250MG TAB,SA DAYS:90",
"pDTransDescOutput": "   DRUG:NIACIN (SLO-NIACIN) 250MG TAB,SA DAYS:90",
"pDTransAmt": "0.00",
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": null,
"pDDatePostedOutput": "",
"pDTransDesc": "QTY:90 PHY:VELAZQUEZ SANCHEZ,VANESSA",
"pDTransDescOutput": "   QTY:90 PHY:VELAZQUEZ SANCHEZ,VANESSA",
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"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": null,
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"pDTransDesc": "CHG:$24.00",
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"pDRefNo": null
},
{
"pDDatePosted": "10292020",
"pDDatePostedOutput": "10/29/2020",
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"pDTransDescOutput": "COPAY RX#100045028 FILL DATE: 10/27/2020",
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"pDTransAmtOutput": "8.00  ",
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},
{
"pDDatePosted": null,
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"pDTransDesc": "DRUG:CARBAMIDE PEROXIDE 6.5% OTIC SOLN DAYS:14",
"pDTransDescOutput": "   DRUG:CARBAMIDE PEROXIDE 6.5% OTIC SOLN DAYS:14",
"pDTransAmt": "0.00",
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": null,
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"pDTransDesc": "QTY:45 PHY:VELAZQUEZ SANCHEZ,VANESSA CHG:$8.00",
"pDTransDescOutput": "   QTY:45 PHY:VELAZQUEZ SANCHEZ,VANESSA CHG:$8.00",
"pDTransAmt": "0.00",
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": "10292020",
"pDDatePostedOutput": "10/29/2020",
"pDTransDesc": "COPAY RX:100045029 FD:10/27/2020",
"pDTransDescOutput": "COPAY RX#100045029 FILL DATE: 10/27/2020",
"pDTransAmt": "8.00",
"pDTransAmtOutput": "8.00  ",
"pDRefNo": "516-K10J56V"
},
{
"pDDatePosted": null,
"pDDatePostedOutput": "",
"pDTransDesc": "DRUG:MICONAZOLE NITRATE 2% TOP TINCTURE DAYS:30",
"pDTransDescOutput": "   DRUG:MICONAZOLE NITRATE 2% TOP TINCTURE DAYS:30",
"pDTransAmt": "0.00",
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"pDRefNo": null
},
{
"pDDatePosted": null,
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"pDTransAmt": "0.00",
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": "11192020",
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"pDTransDescOutput": "PAYMENT POSTED ON 11/19/2020",
"pDTransAmt": "-16.76",
"pDTransAmtOutput": "16.76- ",
"pDRefNo": "516-K00JZPJ"
},
{
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"pDTransDescOutput": "PAYMENT POSTED ON 11/19/2020",
"pDTransAmt": "-15.26",
"pDTransAmtOutput": "15.26- ",
"pDRefNo": "516-K00N8XA"
},
{
"pDDatePosted": "11192020",
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},
{
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"pDRefNo": "516-K00S829"
},
{
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"pDTransDescOutput": "PAYMENT POSTED ON 11/19/2020",
"pDTransAmt": "-23.00",
"pDTransAmtOutput": "23.00- ",
"pDRefNo": "516-K00SZBK"
},
{
"pDDatePosted": "11192020",
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"pDTransAmtOutput": "15.00- ",
"pDRefNo": "516-K00UY3W"
},
{
"pDDatePosted": "11192020",
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"pDTransDesc": "PAYMENT",
"pDTransDescOutput": "PAYMENT POSTED ON 11/19/2020",
"pDTransAmt": "-15.00",
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "516-K00WDZQ"
},
{
"pDDatePosted": "11192020",
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"pDTransDescOutput": "PAYMENT POSTED ON 11/19/2020",
"pDTransAmt": "-55.00",
"pDTransAmtOutput": "55.00- ",
"pDRefNo": "516-K10J56V"
},
{
"pDDatePosted": "11232020",
"pDDatePostedOutput": "11/23/2020",
"pDTransDesc": "OUTPATIENT CARE(NSC) VISIT DATE: 10/27/2020",
"pDTransDescOutput": "OUTPATIENT CARE VISIT DATE: 10/27/2020",
"pDTransAmt": "15.00",
"pDTransAmtOutput": "15.00  ",
"pDRefNo": "516-K10LD3I"
},
{
"pDDatePosted": "11232020",
"pDDatePostedOutput": "11/23/2020",
"pDTransDesc": "OUTPATIENT CARE(NSC)",
"pDTransDescOutput": "OUTPATIENT CARE",
"pDTransAmt": "-15.00",
"pDTransAmtOutput": "15.00- ",
"pDRefNo": "516-K10LD3I"
},
{
"pDDatePosted": "11232020",
"pDDatePostedOutput": "11/23/2020",
"pDTransDesc": "COMMENT: K10KM1P PD $15.00 DOS:10/27/20",
"pDTransDescOutput": "   COMMENT: K10KM1P PD $15.00 DOS:10/27/20",
"pDTransAmt": "0.00",
"pDTransAmtOutput": ".00  ",
"pDRefNo": "516-K10LD3I"
},
{
"pDDatePosted": "12012020",
"pDDatePostedOutput": "12/01/2020",
"pDTransDesc": "COPAY RX:100046632 FD:11/18/2020",
"pDTransDescOutput": "COPAY RX#100046632 FILL DATE: 11/18/2020",
"pDTransAmt": "15.00",
"pDTransAmtOutput": "15.00  ",
"pDRefNo": "516-K10LT59"
},
{
"pDDatePosted": null,
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"pDTransDesc": "DRUG:AMLODIPINE BESYLATE 10MG TAB DAYS:90",
"pDTransDescOutput": "   DRUG:AMLODIPINE BESYLATE 10MG TAB DAYS:90",
"pDTransAmt": "0.00",
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": null,
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"pDTransDesc": "QTY:90 PHY:VELAZQUEZ SANCHEZ,VANESSA",
"pDTransDescOutput": "   QTY:90 PHY:VELAZQUEZ SANCHEZ,VANESSA",
"pDTransAmt": "0.00",
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"pDRefNo": null
},
{
"pDDatePosted": null,
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"pDTransDesc": "CHG:$15.00",
"pDTransDescOutput": "   CHG:$15.00",
"pDTransAmt": "0.00",
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
},
{
"pDDatePosted": "12162020",
"pDDatePostedOutput": "12/16/2020",
"pDTransDesc": "COPAY RX:100030241A FD:12/12/2020",
"pDTransDescOutput": "COPAY RX#100030241A FILL DATE: 12/12/2020",
"pDTransAmt": "15.00",
"pDTransAmtOutput": "15.00  ",
"pDRefNo": "516-K10MUDV"
},
{
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"pDTransDesc": "DRUG:ATENOLOL 25MG TAB DAYS:90 QTY:90",
"pDTransDescOutput": "   DRUG:ATENOLOL 25MG TAB DAYS:90 QTY:90",
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"pDRefNo": null
},
{
"pDDatePosted": null,
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"pDTransDesc": "PHY:VELAZQUEZ SANCHEZ,VANESSA CHG:$15.00",
"pDTransDescOutput": "   PHY:VELAZQUEZ SANCHEZ,VANESSA CHG:$15.00",
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"pDRefNo": null
},
{
"pDDatePosted": "12212020",
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"pDTransDesc": "OUTPATIENT CARE(NSC) VISIT DATE: 11/13/2020",
"pDTransDescOutput": "OUTPATIENT CARE VISIT DATE: 11/13/2020",
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"pDTransAmtOutput": "15.00  ",
"pDRefNo": "516-K10N4AR"
},
{
"pDDatePosted": "12212020",
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"pDTransAmtOutput": "15.00- ",
"pDRefNo": "516-K10N4AR"
},
{
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"pDTransDescOutput": "INTEREST/ADM. CHARGE (Int:0.32 Adm:1.64 Other:0.00",
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"pDTransAmtOutput": "1.96  ",
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}
],
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"city": "PRESCOTT",
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"facilityName": "Ralph H. Johnson Department of Veterans Affairs Medical Center"
},
"debtType": "COPAY",
"resolutionOption": "waiver",
"resolutionComment": "",
"resolutionWaiverCheck": true
}
]
}
Raw
03-presubmit-minimal.json
{
"questions": {
"hasRecreationalVehicle": false,
"hasVehicle": false,
"hasRealEstate": false,
"hasDependents": "0",
"isMarried": false,
"vetIsEmployed": false
},
"view:components": {
"view:realEstateAdditionalInfo": {},
"view:maritalStatus": {},
"view:veteranInfo": {},
"view:vaBenefitsOnFile": {},
"view:vehicleInfo": {},
"view:recVehicleInfo": {},
"view:assetInfo": {}
},
"personalData": {
"veteranFullName": {
"first": "Mark",
"last": "Webb",
"middle": "",
"suffix": "Jr."
},
"dateOfBirth": "1950-10-04",
"address": {
"livesOnMilitaryBaseInfo": {},
"country": "USA",
"street": "123 Faker Street",
"city": "Bogusville",
"state": "GA",
"postalCode": "30058"
},
"telephoneNumber": "4445551212",
"emailAddress": "[email protected]",
"veteranContactInformation": {
"email": "[email protected]",
"mobilePhone": {
"areaCode": "510",
"countryCode": "1",
"createdAt": "2020-06-12T16:56:37.000+00:00",
"extension": "",
"effectiveEndDate": null,
"effectiveStartDate": "2020-07-14T19:07:45.000+00:00",
"id": 146766,
"isInternational": false,
"isTextable": null,
"isTextPermitted": null,
"isTty": null,
"isVoicemailable": null,
"phoneNumber": "9224444",
"phoneType": "HOME",
"sourceDate": "2020-07-14T19:07:45.000+00:00",
"sourceSystemUser": null,
"transactionId": "92c49d39-22b2-4bd6-92b4-0b7e7c63c6a9",
"updatedAt": "2020-07-14T19:07:46.000+00:00",
"vet360Id": "1273780"
},
"address": {
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"addressLine2": "c/o Pixar",
"addressPou": "CORRESPONDENCE",
"addressType": "DOMESTIC",
"city": "Emeryville",
"countryName": "United States",
"countryCodeIso2": "US",
"countryCodeIso3": "USA",
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"countyCode": null,
"countyName": null,
"createdAt": "2020-05-30T03:57:20.000+00:00",
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"sourceDate": "2020-07-10T20:10:45.000+00:00",
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}
},
"employmentHistory": {
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"spouse": {}
},
"spouseFullName": {}
},
"personalIdentification": {
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},
"selectedDebts": [],
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"pSStatementDate": "05242023",
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"pSProcessDate": "12102020",
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"pHPatientLstNme": "HHUFHYULSEHU",
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"pHZipCde": "45424",
"pHZipCdeOutput": "45424",
"pHCtryNme": null,
"pHAmtDue": 105.24,
"pHAmtDueOutput": "105.24  ",
"pHPrevBal": 103.21,
"pHPrevBalOutput": "103.21  ",
"pHTotCharges": 2.03,
"pHTotChargesOutput": "2.03  ",
"pHTotCredits": 0,
"pHTotCreditsOutput": ".00  ",
"pHNewBalance": 105.24,
"pHNewBalanceOutput": "105.24  ",
"pHSpecialNotes": null,
"pHroParaCdes": "0125304050556065708085",
"pHNumOfLines": 2,
"pHDfnNumber": 197750,
"pHCernerStatementNumber": 0,
"pHCernerPatientId": " ",
"pHCernerAccountNumber": " ",
"pHIcnNumber": " ",
"pHAccountNumber": 7570000000197750,
"pHLargeFontIndcator": 0,
"details": [
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"pDDatePostedOutput": "",
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"pDTransDescOutput": "INTEREST/ADM. CHARGE (Int:0.10 Adm:1.93 Other:0.00",
"pDTransAmt": 2.03,
"pDTransAmtOutput": "2.03  ",
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},
{
"pDDatePosted": null,
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"pDTransDesc": "Please refer to previous statement of rights.",
"pDTransDescOutput": "   Please refer to previous statement of rights.",
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"pDRefNo": null
}
],
"station": {
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"staTAddress3": null,
"city": "Columbus",
"state": "OH",
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"facilityName": "Chalmers P. Wylie Veterans Outpatient Clinic"
},
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}
],
"debt": {
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{
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}
],
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},
"socialSecurity": {
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},
"additionalIncome": {
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},
"benefits": {
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},
"assets": {},
"view:combinedFinancialStatusReport": true,
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"income": [
{
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}
]
}
Raw
04-submissionObject-minimal.json
{
"personalIdentification": {
"ssn": "4437",
"fileNumber": "4437",
"fsrReason": ""
},
"personalData": {
"veteranFullName": {
"first": "Mark",
"middle": "",
"last": "Webb"
},
"address": {
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"city": "Emeryville",
"stateOrProvince": "CA",
"zipOrPostalCode": "94608",
"countryName": "US"
},
"telephoneNumber": "(510) 922-4444",
"dateOfBirth": "10/04/1950",
"married": false,
"spouseFullName": {
"first": "",
"middle": "",
"last": ""
},
"agesOfOtherDependents": [],
"employmentHistory": []
},
"income": [
{
"veteranOrSpouse": "VETERAN",
"monthlyGrossSalary": "0.00",
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"socialSecurity": "0.00",
"otherDeductions": {
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}
},
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"otherIncome": {
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},
"totalMonthlyNetIncome": "0.00"
},
{
"veteranOrSpouse": "SPOUSE",
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"otherDeductions": {
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}
},
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},
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}
],
"expenses": {
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"food": "0.00",
"utilities": "0.00",
"otherLivingExpenses": {
"name": "",
"amount": "0.00"
},
"expensesInstallmentContractsAndOtherDebts": "0.00",
"totalMonthlyExpenses": "0.00"
},
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"amountCanBePaidTowardDebt": "0.00"
},
"assets": {
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"cashOnHand": "0.00",
"usSavingsBonds": "0.00",
"stocksAndOtherBonds": "0.00",
"realEstateOwned": "0.00",
"totalAssets": "0.00"
},
"installmentContractsAndOtherDebts": [],
"totalOfInstallmentContractsAndOtherDebts": {
"originalAmount": "0.00",
"unpaidBalance": "0.00",
"amountDueMonthly": "0.00",
"amountPastDue": "0.00"
},
"additionalData": {
"bankruptcy": {}
},
"applicantCertifications": {
"veteranSignature": "Mark Webb",
"veteranDateSigned": "07/24/2023"
},
"selectedDebtsAndCopays": [
{
"id": "3fa85f64-5717-4562-b3fc-2c963f66afa6",
"pSSeqNum": "1.00",
"pSTotSeqNum": "1.00",
"pSFacilityNum": "757",
"pSFacPhoneNum": null,
"pSTotStatement": "3.00",
"pSStatementVal": "0000037953E",
"pSStatementDate": "05242023",
"pSStatementDateOutput": "05/24/2023",
"pSProcessDate": "12102020",
"pSProcessDateOutput": "12/10/2020",
"pHPatientLstNme": "HHUFHYULSEHU",
"pHPatientFstNme": "CDAA",
"pHPatientMidNme": "A",
"pHAddress1": "7780 RED MAPLE CT",
"pHAddress2": null,
"pHAddress3": null,
"pHCity": "HUBER HEIGHTS",
"pHState": "OH",
"pHZipCde": "45424",
"pHZipCdeOutput": "45424",
"pHCtryNme": null,
"pHAmtDue": "105.24",
"pHAmtDueOutput": "105.24  ",
"pHPrevBal": "103.21",
"pHPrevBalOutput": "103.21  ",
"pHTotCharges": "2.03",
"pHTotChargesOutput": "2.03  ",
"pHTotCredits": "0.00",
"pHTotCreditsOutput": ".00  ",
"pHNewBalance": "105.24",
"pHNewBalanceOutput": "105.24  ",
"pHSpecialNotes": null,
"pHroParaCdes": "0125304050556065708085",
"pHNumOfLines": "2.00",
"pHDfnNumber": "197750.00",
"pHCernerStatementNumber": "0.00",
"pHCernerPatientId": " ",
"pHCernerAccountNumber": " ",
"pHIcnNumber": " ",
"pHAccountNumber": "7570000000197750.00",
"pHLargeFontIndcator": "0.00",
"details": [
{
"pDDatePosted": null,
"pDDatePostedOutput": "",
"pDTransDesc": "INTEREST/ADM. CHARGE (Int:0.10 Adm:1.93 Other:0.00",
"pDTransDescOutput": "INTEREST/ADM. CHARGE (Int:0.10 Adm:1.93 Other:0.00",
"pDTransAmt": "2.03",
"pDTransAmtOutput": "2.03  ",
"pDRefNo": null
},
{
"pDDatePosted": null,
"pDDatePostedOutput": "",
"pDTransDesc": "Please refer to previous statement of rights.",
"pDTransDescOutput": "   Please refer to previous statement of rights.",
"pDTransAmt": "0.00",
"pDTransAmtOutput": ".00  ",
"pDRefNo": null
}
],
"station": {
"facilitYNum": "757",
"visNNum": "10",
"facilitYDesc": "CHALMERS P WYLIE VA ACC (757)",
"cyclENum": "004",
"remiTToFlag": "L",
"maiLInsertFlag": "0",
"staTAddress1": "420 N JAMES RD",
"staTAddress2": null,
"staTAddress3": null,
"city": "Columbus",
"state": "OH",
"ziPCde": "432191834",
"ziPCdeOutput": "43219-1834",
"baRCde": "*432191834203*",
"teLNumFlag": "S",
"teLNum": "1-866-812-0318",
"teLNum2": null,
"contacTInfo": null,
"dM2TelNum": null,
"contacTInfo2": null,
"toPTelNum": null,
"lbXFedexAddress1": null,
"lbXFedexAddress2": null,
"lbXFedexAddress3": null,
"lbXFedexCity": null,
"lbXFedexState": null,
"lbXFedexZipCde": null,
"lbXFedexBarCde": null,
"lbXFedexContact": null,
"lbXFedexContactTelNum": null,
"facilityName": "Chalmers P. Wylie Veterans Outpatient Clinic"
},
"debtType": "COPAY"
}
]
}
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