Application and Renewal for Health Benefits

ICR 200412-2900-005

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
28252 Migrated
ICR Details
2900-0091 200412-2900-005
Historical Inactive 200402-2900-007
VA
Application and Renewal for Health Benefits
Revision of a currently approved collection   No
Regular
Comment filed on proposed rule and continue 12/29/2004
Retrieve Notice of Action (NOA) 12/28/2004
OMB files comment at this time and will review the request for revision following public notice and comment of changes requested in the VA Notice of Public Rulemaking entitled "Eligibility for Health Care Benefits for Certain Filipino Veterans in the United States."
  Inventory as of this Action Requested Previously Approved
06/30/2007 12/31/2007 07/31/2007
1,900,000 0 1,900,000
1,005,000 0 0
0 0 0

Collects information to enroll for health care benefits, establishes basic eligibilty, identifies 3rd party health insurance coverage and identifies prescription copayment and serves as a mechanism to make changes upon admission or yearly financial updates.

None
None


No

1
IC Title Form No. Form Name
Application and Renewal for Health Benefits VA-10, VA-10EZ, VA-10EZR

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.
12/28/2004


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