Information Collection

CHAMPVA Application for Benefits

IC 246417 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⚠️ Notice: This information collection may be referencing outdated material.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 10-10d CHAMPVA Application for Benefits	Form
10-10d CHAMPVA Application for Benefits vha-10-10d-fill_CHAMPVA_Application for Benefits.pdf www.gov/vaforms/Search_action.asp	Form
10-10d CHAMPVA Application for Benefits vha-10-10d-fill_CHAMPVA_Application for Benefits.pdf www.gov/vaforms/Search_action.asp	Form

IC Title:

CHAMPVA Application for Benefits

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	10-10d	CHAMPVA Application for Benefits	vha-10-10d-fill_CHAMPVA_Application for Benefits.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: 53,775

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	53,775	53,775
Annual IC Time Burden (Hours)	8,963	8,963
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.