Memo on revisions to VA form 10-0103

Department of Memorandum

Veterans Affairs

Date: May 31, 2013

From: VHA PRA Compliance Liaison (10B4)

Subject: Revisions to VA Form 10-0103

To: VA OMB Desk Officer

VA Form 10-0103, Veterans Application for Assistance (in Acquiring Home Improvements and Structural Alterations) has been revised to simplify fillable form fields:

Section I – Veteran/Service member Application

Previous 2010 form:

• PRA and PA statement has been removed from top of page to bottom of page 2.

• Highlighted fillable fields 3, 6, 7, 8 and 9 have been removed.

Revised 2013 form: Page 1 of 2

• Page 1, Section I: PRA and PA Statement information has been moved to bottom of page 2

• Top block “HISA” alterations has been revised to include Date 1 and Date 2

• Second block “Have you made previous application…” question blocks have been added.

• Number 5. “email address” is included as new fillable field

• Number 6. “what type of improvements, alterations…” new fillable field has been added

• Number 8. Is new with three check boxes

• Certification statement at bottom of page 1 has been revised to include HISA benefits
  statement with yes or no check boxes.

• The expiration date will be included in the form header with the OMB control number and estimated burden

Previous 2010 form: Section 2, Page 2

• Page 2, “Home Improvement” red text block 1: First checkbox text has been revised

• Text block 1 Yellow highlighted area boxes have been deleted

• Block 2, “The work to be performed”…: has been removed

• Block 3, Cost Limitation “Note” has been removed

• Block 4 has been revised.

Revised 2013 form: Page 2 of 2

• Page 2, Section 2 first check box revised

• Check box 4 was deleted

• Check boxes 6 and 7 were deleted.

• Cost Limitation” becomes text block 2, centered, minus “Note.”

• Block 4. has been revised to include 2 new check boxes, “Advanced Payment” and
  “Final Payment.”