VA Form 10-10HS -- Request for Hardship Determination

VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR and 10-10HS

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0091 can be found here:

Documents and Forms

Document Name Document Type
Form 10-10HS VA Form 10-10HS -- Request for Hardship Determination Form and Instruction
10-10HS VA Request for Hardship Determination vha-10-10HS-fill.pdf www.va.gov/vaforms/medical/pdf/vha-10-10HS.pdf Form and Instruction
10-10HS VA Request for Hardship Determination vha-10-10HS-fill.pdf www.va.gov/vaforms/medical/pdf/vha-10-10HS.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	VA Form 10-10HS -- Request for Hardship Determination	Agency IC Tracking Number:	2900-0091

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10HS	VA Request for Hardship Determination	vha-10-10HS-fill.pdf	http://www.va.gov/vaforms/medical/pdf/vha-10-10HS.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7,000	7,000
Annual IC Time Burden (Hours)	1,750	1,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.