Information Collection Request
VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR and 10-10HS
ICR 202402-2900-001 · OMB 2900-0091 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 2900-0091 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form 10-10EZR VA Form 10-10EZR |
Form and Instruction | Modified | Missing upstream |
| Form 10-10EZ VA Form 10-10EZ |
Form and Instruction | Modified | Repair queued |
| Form 10-10HS VA Form 10-10HS -- Request for Hardship Determination |
Form and Instruction | Unchanged | Missing upstream |
 2900-0091_Emergency OMB PRA Clearance Request Memorandum_(PACT Act-Sec 103)_02022024.pdf |
Supplementary Document | Uploaded 2024-02-06 | Missing upstream |
 SSA_2900-0091_VA Health Benefits Forms_10-10EZ and 10-10EZR_revised 02022024.docx |
Supporting Statement A | Uploaded 2024-02-06 | Missing upstream |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 256200 |  VA Form 10-10EZR |
Form and Instruction | Modified | |
| 256198 | VA Form 10-10EZ |
Form and Instruction | Modified | |
| 244175 | VA Form 10-10HS -- Request for Hardship Determination |
Form and Instruction | Unchanged |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | VA |
| OMB Control No | 2900-0091 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202209-2900-014 |
| Agency Tracking No | 2900-0091 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 2024-02-20 |