Form 10-304 Waiver Statement

OMB Control Number: 2900-0867
Estimated Burden: 20 minutes
Expiration Date: 01/31/2025

WAIVER STATEMENT
PRIVACY ACT INFORMATION: The information you furnish on this form is almost always used to determine if you are eligible for waiver of a debt, for the
acceptance of a compromise offer or for a payment plan. Disclosure is voluntary. However, if the information is not furnished, your eligibility for waiver, compromise or a
payment plan may be affected. The responses you submit are confidential and protected from unauthorized disclosure by 38 U.S.C. 5701. The information may be disclosed
outside the Department of Veterans Affairs (VA) only when authorized by the Privacy Act of 1974, as amended. The routine uses for which VA may disclose the
information can be found in VA systems of records, including 58VA21/22, Compensation, Pension, Education and Rehabilitation Records-VA, and 88VA244, Accounts
Receivable Records-VA. VA systems of records and alterations to the systems are published in the Federal Register. Any information provided by you, including your
Social Security Number, may be used in computer matching programs conducted in connection with any proceeding for the collection of an amount owed by virtue of your
participation in any benefit program administered by VA.
THE PAPERWORK REDUCTION ACT OF 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section
3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid
OMB number. We anticipate that the time expended by all individuals who must complete this form will average 20 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the form.

GENERAL INFORMATION
1. VETERAN'S NAME (Last, First, Middle Name)

2. SOCIAL SECURITY NUMBER

3. STATEMENT
I hereby request a waiver from my indebtedness to the government for co-payment charges incurred in conjunction with care provided to me. I understand
that a debt cannot be waived if it has been more than 180 days since it first appeared on my statement and a waiver, if granted, may not eliminate my debt
in total. I understand that I will be responsible for any debt not waived and any new co-payments that appear on future billing statements. The reason I have
requested a waiver (explain your change in circumstances):

4. SIGNATURE OF APPLICANT

VA FORM
SEP 2021

10-304

5. DATE SIGNED (MM/DD/YYYY)

HEC

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