Camp Lejeune Family Member Program Claim Form

RIN 2900-AO79 Reimbursement of Certain Medical Expenses for Camp Lejeune Family Members

OMB: 2900-0822

IC ID: 210895

Information Collection (IC) Details

View Information Collection (IC)

Camp Lejeune Family Member Program Claim Form
 
No New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 10-10068a Camp Lejeune Family Member Program Claim Form 10-10068a DRAFT CLFM Claim Form 032614.pdf Yes No Fillable Printable

Health Health Care Services

 

1,629 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 17,919 17,919 0 0 0 0
Annual IC Time Burden (Hours) 4,480 4,480 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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