Information Collection

Application For Medical Benefits For Dependents Or Survivors - Champva

IC 174525 under ICR 198610-2900-012 · OMB 2900-0219.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS - CHAMPVA	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA 10-10D				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	99,996	93,496	6,500
Annual IC Time Burden (Hours)	8,333	7,791	542
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.