Information Collection

Documentation of Indian or Urban Indian Status for Veteran Copayment Exemption

IC 257252 under ICR 202303-2900-008 · OMB 2900-0920.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-334 Documentation of Indian or Urban Indian Status for Veteran Copayment Exemption	Form and Instruction
10-334 Tribal Documentation Form VA Form 10-334_Tribal Documentation Form.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

2900-0920

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 17.108 38 CFR 17.110 38 CFR 17.111 38 CFR 17.4600

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 and Instruction	10-334	Tribal Documentation Form	VA Form 10-334_Tribal Documentation Form.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 24VA19 âPatient Medical Record â VA"

FR Citation: 74 FR 60040

Number of Respondents: 25,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25,000	25,000
Annual IC Time Burden (Hours)	6,250	6,250
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.