Application for Health Benefits

ICR 200303-2900-007

OMB: 2900-0091

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
42187 Migrated
ICR Details
2900-0091 200303-2900-007
Historical Active 200201-2900-009
VA
Application for Health Benefits
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 03/18/2003
Retrieve Notice of Action (NOA) 03/18/2003
  Inventory as of this Action Requested Previously Approved
03/31/2005 03/31/2005 03/31/2005
5,985,000 0 3,485,000
2,655,417 0 2,613,750
0 0 0

Collects information to enroll for health care benefits, establishes basic eligiiblity, identifies 3rd party health insurance coverage and identifies prescription copayment.

None
None


No

1
IC Title Form No. Form Name
Application for Health Benefits VA-10-10EZ

  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 5,985,000 3,485,000 0 2,500,000 0 0
Annual Time Burden (Hours) 2,655,417 2,613,750 0 41,667 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.
03/18/2003


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