Approved
consistent with the following terms of clearance: OMB encourages VA
to continue Departmental efforts aimed at providing respondents
with a fully electronic version of associated forms that may be
completed and submitted electronically and that include the
recognition of electronic signatures.
Inventory as of this Action
Requested
Previously Approved
10/31/2017
36 Months From Approved
10/31/2014
22,213
0
464,155
3,702
0
33,079
0
0
0
VA Form 10-2065 is part of the
Decedent Affairs Package. The form is completed during the
interview with relatives of the deceased, and identifies the
funeral home to which the remains are to be released. The family
signs the form designating that it reflects their wishes. It is
used as a control document when VA is requested to arrange for the
transportation of the deceased from the place of death to the place
of burial, and/or when burial is requested in a National
Cemetery.
US Code:
38
USC 1728 Name of Law: Reimbursement of certain medical
expenses
US Code: 38
USC 111 Name of Law: Payments or allowances for beneficiary
travel
US Code: 38
USC 1703 Name of Law: Contracts for hospital care and medical
services in non-Department facilities
US Code: 38
USC 1725 Name of Law: Reimbursement for emergency treatment
VA Forms 10-2511; 10-583; and
Form 10-7078 are forms that are not completed by respondents. They
are internal VA forms, therefore burden hours are no longer
applicable.
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.
Form 10-583 Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority and Invoice for Travel by Ambulance or Other Hired Vehicle; Authorization and Invoice...
Memo Request to Discontinue VA Form.docx
Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority and Invoice for Travel by Ambulance or Other Hired Vehicle; Authorization and Invoice...