Information Collection

Application for Extended Care Services

IC 28899 under ICR 201105-2900-005 · OMB 2900-0629.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0629 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10EC Application for Extended Care Services	Form and Instruction
10-10EC Application for Extended Care Benefits 10-10EC-fill1(v2).pdf www.va.gov/vaforms	Form and Instruction

IC Title:

Application for Extended Care Services

Agency IC Tracking Number:

2900-0629

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10EC	Application for Extended Care Benefits	10-10EC-fill1(v2).pdf	https://www.va.gov/vaforms	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	9,000	9,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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