VETERANS ADMINISTRATION - APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS AND SURVIVORS - CHAMPVA

ICR 198011-2900-064

OMB: 2900-0219

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
2900-0219 198011-2900-064
Historical Active 197904-2900-002
VA
VETERANS ADMINISTRATION - APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS AND SURVIVORS - CHAMPVA
No material or nonsubstantive change to a currently approved collection   No
Emergency 11/14/1980
Approved with change 11/14/1980
Retrieve Notice of Action (NOA) 11/14/1980
  Inventory as of this Action Requested Previously Approved
04/30/1984 04/30/1984 04/30/1984
30,000 0 15,000
7,500 0 3,750
0 0 0

USED TO RECORD INFORMATION NEEDED BY VA PERSONNEL TO DETERMINE ELIGIBILITY FOR BENEFITS UNDER TITLE 38 USC 613 BY PERSONS APPLYING UNDER THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE VETERANS ADMINISTRATION (CHAMPVA).

None
None


No

1
IC Title Form No. Form Name
VETERANS ADMINISTRATION - APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS AND SURVIVORS - CHAMPVA VA 10-10D

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 30,000 15,000 0 15,000 0 0
Annual Time Burden (Hours) 7,500 3,750 0 3,750 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/14/1980


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