Information Collection

Waiver Statement

IC 249242 under ICR 202501-2900-009 · OMB 2900-0867.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-304 Waiver Statement	Form and Instruction
Form 10-304 Waiver Statement Waiver Statement	Form and Instruction
10-304 Waiver Statement VA Form 10-304_revised draft_2025.pdf	Form and Instruction
10-304 Waiver Statement VA Form 10-304_revised draft_2025.pdf	Form and Instruction

IC Title:

Waiver Statement

Agency IC Tracking Number:

2900-0867

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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	10-304				Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 44,008

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	Previously Approved
Annual Number of Responses for this IC	44,008	44,008
Annual IC Time Burden (Hours)	14,669	14,669
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.

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