APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS - CHAMPVA

ICR 198407-2900-008

OMB: 2900-0219

Federal Form Document

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ICR Details
2900-0219 198407-2900-008
Historical Active 198210-2900-028
VA
APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS - CHAMPVA
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 09/25/1984
Retrieve Notice of Action (NOA) 07/30/1984
  Inventory as of this Action Requested Previously Approved
04/30/1987 04/30/1987
6,500 0 0
542 0 0
0 0 0

THE SPOUSE, CHILD, OR SURVIVING SPOUSE OF A VETERAN WHO HAS A TOTAL DISABILITY, PERMANENT IN NATURE, RESULTING FROM A SERVICE-CONNECTED DISABILITY, OR WHO DIED AS A RESULT OF A SERVICE-CONNECTED DISABILITY MAY COMPLETE THIS APPLICATION TO OBTAIN MEDICAL BENEFITS AVAILABLE TO THEM THROUGH THE VETERANS ADMINISTRATION.

None
None


No

1
IC Title Form No. Form Name
APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR 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 6,500 0 0 0 6,500 0
Annual Time Burden (Hours) 542 0 0 0 542 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
07/30/1984


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