Information Collection

Applications for Motor Vehicle Adaptive Equipment and HISA Services

IC 28432 under ICR 202402-2900-018 · OMB 2900-0188.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-0103 Applications for Motor Vehicle Adaptive Equipment and HISA Services	Form
10-0103 VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Im VA Form 10-0103_updated May 2024.pdf www.va.gov/vaforms	Form
10-0103 VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Im VA Form 10-0103_updated May 2024.pdf www.va.gov/vaforms	Form
10-1394 APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE VA Form 10-1394_updated May 2024.pdf www.va.gov/vaforms	Form
10-1394 APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE VA Form 10-1394_updated May 2024.pdf www.va.gov/vaforms	Form

IC Title:

Agency IC Tracking Number:

2900-0188

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 17

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	10-0103	VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvement and Structural Alterations	VA Form 10-0103_updated May 2024.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-1394	APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE	VA Form 10-1394_updated May 2024.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,000

Number of Respondents for Small Entity: 1

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	21,000	-50,200	71,200
Annual IC Time Burden (Hours)	2,750	-2,988	5,738
Annual IC Cost Burden (Dollars)	0	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.