Information Collection

Champva Claim Form And Application For Medical Benefits For Dependents Or Survivors

IC 147624 under ICR 199308-2900-007 · OMB 2900-0219.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	CHAMPVA CLAIM FORM AND APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS	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
Form	10-7959A				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 329,600	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
Annual Number of Responses for this IC	329,600	329,600
Annual IC Time Burden (Hours)	27,467	27,467
Annual IC Cost Burden (Dollars)	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.