Information Collection

CHAMPVA Application, Claim, OHI Certification, and Potential Liability

IC 147625 under ICR 199508-2900-005 · OMB 2900-0219.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0219 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	CHAMPVA Application, Claim, OHI Certification, and Potential Liability	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	10-10D	Yes	Yes
Form	10-7959C	Yes	Yes
Form	10-7959D	Yes	Yes
Form	10-7959A	Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 397,600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 38 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	397,600	397,600	0
Annual IC Time Burden (Hours)	30,033	2,566	27,467
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.