Information Collection

CHAMPVA Potential Liability Claim Form

IC 246408 under ICR 202102-2900-011 · OMB 2900-0219.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0219 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-7959d CHAMPVA Potential Liability Claim Form	Form
10-7959d CHAMPVA Potential Liability Claim Form vha-10-7959d-fill_CHAMPVA_Potential Liability Claim.pdf www.gov/vaforms/Search_action.asp	Form
10-7959d CHAMPVA Potential Liability Claim Form vha-10-7959d-fill_CHAMPVA_Potential Liability Claim.pdf www.gov/vaforms/Search_action.asp	Form

IC Title:

CHAMPVA Potential Liability Claim Form

Agency IC Tracking Number:

2900-0219

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 1.900 38 CFR 17.900 through 17.905

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	10-7959d	CHAMPVA Potential Liability Claim Form	vha-10-7959d-fill_CHAMPVA_Potential Liability Claim.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,045

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,045	2,045
Annual IC Time Burden (Hours)	239	239
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.