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Federal forms, ICRs, and supporting documents

Information Collection Request

APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS - CHAMPVA

ICR 198704-2900-012 · OMB 2900-0219 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
147622 APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS - CHAMPVA Form Migrated
ICR Details
2900-0219 198704-2900-012
Historical Active 198610-2900-012
VA
APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS - CHAMPVA
Revision of a currently approved collection   No
Regular
Approved without change 06/10/1987
Retrieve Notice of Action (NOA) 04/08/1987
  Inventory as of this Action Requested Previously Approved
04/30/1990 04/30/1990 04/30/1987
9,600 0 99,996
787 0 8,333
0 0 0
THE SPOUSE, CHILD OR SURVIVING SPOUSE OF A VETERAN WHO HAS A TOTAL DISABILITY, PERMANENT IN NATURE, RESULTING FROM A SERVICE-CONNECTED DISABILITY, OR WHO DIED AS A RESULT OF A SERVICE-CONNECTED DISABILITY, MAY COMPLETE THIS APPLICATION TO OBTAIN MEDICAL BENEFITS AVAILABLE TO THEM THROUGH THE VETERANS ADMINISTRATION.
None
None
No
1
IC Title Form No. Form Name
APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS - CHAMPVA VA 10-10D
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 9,600 99,996 0 -90,396 0 0
Annual Time Burden (Hours) 787 8,333 0 -7,546 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/08/1987