Form 10-304 Waiver Statement

OMB Control Number: 2900-0867
Estimated Burden: 20 minutes
Expiration Date: XX/XX/20XX

WAIVER STATEMENT
PRIVACY ACT INFORMATION: The information you furnish on this form is almost always used to determine if you are eligible for waiver of a debt, for the
acceptance of a compromise offer or for a payment plan. Disclosure is voluntary. However, if the information is not furnished, your eligibility for waiver, compromise or a
payment plan may be affected. The responses you submit are confidential and protected from unauthorized disclosure by 38 U.S.C. 5701. The information may be disclosed
outside the Department of Veterans Affairs (VA) only when authorized by the Privacy Act of 1974, as amended. The routine uses for which VA may disclose the
information can be found in VA systems of records, including 58VA21/22, Compensation, Pension, Education and Rehabilitation Records-VA, and 88VA244, Accounts
Receivable Records-VA. VA systems of records and alterations to the systems are published in the Federal Register. Any information provided by you, including your
Social Security Number, may be used in computer matching programs conducted in connection with any proceeding for the collection of an amount owed by virtue of your
participation in any benefit program administered by VA.
VA BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The OMB control number for this project is 2900-0867, and it expires XX/XX/20XX. Public reporting burden for this collection of information
is estimated to average 20 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of
information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-0867 in any
correspondence. Do not send your completed VA Form 10-304 to this email address.

GENERAL INFORMATION

1. VETERAN'S NAME (Last, First, Middle Name)

2. SOCIAL SECURITY NUMBER

3. STATEMENT
I hereby request a waiver from my indebtedness to the government for co-payment charges incurred in conjunction with care provided to me. I understand
that a debt cannot be waived if it has been more than 180 days since it first appeared on my statement and a waiver, if granted, may not eliminate my debt
in total. I understand that I will be responsible for any debt not waived and any new co-payments that appear on future billing statements. The reason I have
requested a waiver (explain your change in circumstances):

4. SIGNATURE OF APPLICANT

VA FORM
XXX 2025

10-304

5. DATE SIGNED (MM/DD/YYYY)

HEC

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