Form 10-10068 Camp Lejeune Family Member Program Application

OMB Number 2900-XXXX
Burden Hours: 30 minutes
OMB EXP Date: XX/XX/XXXX

Department of Veterans Affairs

Camp Lejeune Family Member Program Application
Important! For expedited processing, please submit your application online at:
https://clfamilymembers.fsc.va.gov or for standard processing, mail the completed form to:
Department of Veterans Affairs, Financial Services Center PO Box 149200 Austin, TX 78714-9200

1. Applicant Information
Last Name

First Name

Social Security Number

Date of Birth (MMDDYYYY)

Mailing Address

MI

City

State Zip Code

If you reside outside the United States enter address below

Email Address

Gender

Please indicate if you would like to receive correspondence via
Phone Number

email

Female

regular mail

Alt Phone Number

(include area code)

Male

(include area code)

Relationship to the Veteran during the period January 1, 1957 through December 31, 1987:
Spouse

Child

(provide a copy of marriage certificate)

(provide a copy of birth certificate)

Legal Dependent State your relationship

Stepchild

(provide a copy of birth certificate)

(provide documentation of relationship):

2. Residency Information
Did you reside on Camp Lejeune for 30 days or more between January 1, 1957 and December 31, 1987?

Yes

No

Dates resided on Camp Lejeune:
From (MM/YYYY)

To

(MM/YYYY)

Address (if known) on Camp Lejeune:

Do you have documentation verifying your residency on Camp Lejeune?
Yes
No
If yes, please enclose a copy of the documentation with your application. Documentation may include a utility bill, pay
stub, tax forms, or similar documentation.

3. Conditions/Illnesses
Have you been diagnosed with any of the following conditions?
The following conditions/illnesses may be related to your exposure to contaminated water at Camp Lejeune while living
there for at least thirty days between 1957-1987. Please check the box for any condition for which you have received a
diagnosis (you do not need to have been previously diagnosed to be eligible).
Bladder cancer
Breast cancer
Esophageal cancer
Kidney cancer
Lung cancer

Leukemia
Multiple myeloma
Myelodysplastic syndrome
Non-Hodgkin's lymphoma

Scleroderma
Female infertility* Dates
Renal toxicity
Miscarriage* Dates
Hepatic steatosis
Neurobehavioral effects

*Please indicate the dates of Miscarriage and Female Infertility.
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Do you have health care coverage?

4. Health Care Coverage
No

Yes

Note: This includes coverage you may have through an employer, spouse, significant other or federal/state health care benefit plan. Health care
coverage may also be referred to as health care insurance.

Effective Date

(MMDDYYYY)

Medicare Part B Effective Date

(MMDDYYYY)

Medicare Part A

Medicare Advantage Effective Date (MMDDYYYY)
Medicare Part D Effective Date (MMDDYYYY)
Medicaid/State Assistance
TRICARE

Effective Date (MMDDYYYY)

Effective Date (MMDDYYYY)

CHAMPVA Effective Date

(MMDDYYYY)

Please complete the following if you have other health care coverage not identified above.
Effective Date (MMDDYYYY)
Name of Primary Insurance:
Effective Date

Name of Secondary Insurance:
Does your health care coverage provide Pharmacy benefits? Yes

(MMDDYYYY)

HMO

PPO

HMO

PPO

No

5 Veteran Information
Last Name

First Name

Social Security Number (if known)

Phone Number (include area code)

Date of Birth

Is Veteran deceased?
No
Yes

(MMDDYYYY)

Gender
Male

Female

List Unit(s) and Rank(s) while assigned to Camp Lejeune

Dates Stationed at Camp Lejeune (If Known):
To: (MM/YYYY)

From (MM/YYYY)

MI

Unit(s)
Rank(s)

6. Certification
I hereby apply to the Camp Lejeune Family Member (CLFM) Program and give permission for my personal information to
be used by appropriate Federal Government agencies, Federal Government contractors and other Government entities to
determine if I am eligible for the CLFM Program.
By my signature I attest that I have answered the questions truthfully and that I understand the following: Any person who
knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to gain enrollment
in the CLFM Program to which that person is not entitled is subject to civil and/or administrative remedies as well as felony
criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both.
I certify that the above information is correct and true to the best of my knowledge and belief. (Sign and date on below.)
Signature

Date

If certification is signed by a person other than an applicant, complete the following:
Last Name

First Name

Mailing Address
City
VA FORM
JUL 2013

State

10-10068

Zip Code

Phone Number (include area code)

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Should you apply for the Camp Lejeune Family Member Program?
If the Veteran

And

And

Then

Was on active duty and
served at Camp Lejeune for
30 days or more between
January 1, 1957 and
December 31, 1987;

You were the spouse or
You lived or were in utero You may meet the criteria for VA's
dependent of the Veteran
on Camp Lejeune for 30
Camp Lejeune Family Member
or were in utero of the
days or more between
Program.
Veteran, spouse, or a
January 1, 1957 and
dependent during that
December 31, 1987;
same period;
NOTE TO APPLICANT: You're applying to the Department of Veterans Affairs (VA). VA will consider the information you
provide on this questionnaire as part of their eligibility determination for this program. This program's eligibility criteria will
be determined through the VA. Submission of this application does not guarantee acceptance into this program.

Getting Started: Directions for Applicant, representative or Power of Attorney (POA), please answer all questions.
Applicant Information: Please complete and provide copy of legal documents.
Residency Information: Please answer all questions. If possible, provide copies of documents verifying your residency.
Conditions/Illnesses: Please answer all questions. If you mark the box for Yes, check all the conditions you have been
diagnosed with. A Treating Physician Report form is enclosed for your physician to complete and return with this
application. If you mark the box for No, you may go to the next section.
Health Care Coverage: Please answer all questions and provide your health care coverage, if applicable. (Note: Health
care coverage may also be referred to as health care insurance).
Veteran Information: Please answer all questions, if known.
Certification: Please sign, and date.
For more information go to: www.publichealth.va.gov/exposures/camp-lejeune/index.asp

Customer Service Center: 1-866-372-1144, Fax 512-460-5536
Camp Lejeune Family Member Program
Department of Veterans Affairs, Financial Services Center
PO Box 149200, Austin, TX 78714-9200
The Paperwork Reduction Act: This information collection is in accordance with the clearance requirements of section
3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to
average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be
aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number. The purpose of this data collection is
to determine eligibility for benefits.
Privacy Act Information: The authority for collection of the requested information on this form is 38 USC 1787. The
purpose of collecting this information is to determine your eligibility for reimbursement of health care related to conditions
determined to result from contaminated water while you resided at Camp Lejeune, North Carolina, for a period of at least
30 days. The information you provide may be verified by computer matching programs with authoritative sources such as
the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), Department of Defense
(DoD), Defense Enrollment Eligibility Reporting System (DEERS), Centers for Medicare & Medicaid Services (CMS) or any
other applicable authoritative source at any time. You are requested to provide your social security number as your VA
record is filed and retrieved by this number. You do not have to provide the requested information on this form but if any or
all of the requested information is not provided, it may delay or result in denial of your request for Camp Lejeune Family
Member Program benefits. Failure to furnish the requested information will have no adverse impact on any other VA
benefit to which you may be entitled. The responses you submit are considered private and may be disclosed outside VA
only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records
number 23VA16. For example, information including your social security number may be disclosed to the Department of
Defense, contractors, trading partners, health care providers and other suppliers of health care services to determine your
eligibility for medical benefits and payment for services.
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JUL 2013

10-10068

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