APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS - CHAMPVA

ICR 198610-2900-012

OMB: 2900-0219

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
2900-0219 198610-2900-012
Historical Active 198407-2900-008
VA
APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS - CHAMPVA
No material or nonsubstantive change to a currently approved collection   No
Emergency 10/01/1986
Approved with change 10/01/1986
Retrieve Notice of Action (NOA) 10/01/1986
  Inventory as of this Action Requested Previously Approved
04/30/1987 04/30/1987 04/30/1987
99,996 0 6,500
8,333 0 542
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 99,996 6,500 0 93,496 0 0
Annual Time Burden (Hours) 8,333 542 0 7,791 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.
10/01/1986


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