Information Collection Request

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

ICR 202402-2900-023 · OMB 2900-0091 · Active

⚠️ Notice: This information collection may be outdated.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

Forms and Documents

Forms and supporting documents for this ICR
Document	Type	Status	Availability
Form 10-10EZR Updated VA Form 10-10EZR (2022)	Form and Instruction	Modified	Available
Form 10-10EZR Updated VA Form 10-10EZR (2022)	Form and Instruction	Modified	Missing upstream
Form 10-10EZ Updated VA Form 10-10EZ (2022)	Form and Instruction	Modified	Available
Form 10-10EZ Updated VA Form 10-10EZ (2022)	Form and Instruction	Modified	Repair queued
Form 10-10HS VA Form 10-10HS -- Request for Hardship Determination	Form and Instruction	Unchanged	Available
Form 10-10HS VA Form 10-10HS -- Request for Hardship Determination	Form and Instruction	Unchanged	Repair queued
2900-0091_Non-Substantive Change Memorandum_VA Forms 10-10EZ 10-10EZR_PACT Act-Sect 103 20240229.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-29	Available
2900-0091_Non-Substantive Change Memorandum_VA Forms 10-10EZ 10-10EZR_PACT Act-Sect 103 20240229.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-29	Repair queued
SSA_2900-0091_VA Health Benefits Forms_10-10EZ and 10-10EZR_updated 02272024.docx	Supporting Statement A	Uploaded 2024-02-28	Available
SSA_2900-0091_VA Health Benefits Forms_10-10EZ and 10-10EZR_updated 02272024.docx	Supporting Statement A	Uploaded 2024-02-28	Repair queued

Information collection document groups
IC ID	Collection	Type	Status
256200	Updated VA Form 10-10EZR (2022)	Form and Instruction	Modified
256200	Updated VA Form 10-10EZR (2022)	Form and Instruction	Modified
256198	Updated VA Form 10-10EZ (2022)	Form and Instruction	Modified
256198	Updated VA Form 10-10EZ (2022)	Form and Instruction	Modified
244175	VA Form 10-10HS -- Request for Hardship Determination	Form and Instruction	Unchanged
244175	VA Form 10-10HS -- Request for Hardship Determination	Form and Instruction	Unchanged

Record metadata
Status	Active
Agency/Subagency	VA
OMB Control No	2900-0091
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202209-2900-014
Agency Tracking No	2900-0091
Date Submitted to OIRA	2024-02-29
Requested Expiration Date	1969-12-31