Camp Lejeune Family Member Program Claim Form

RIN 2900-AO79 Reimbursement of Certain Medical Expenses for Camp Lejeune Family Members

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0822 can be found here:

Documents and Forms

Document Name Document Type
Form 10-10068a Camp Lejeune Family Member Program Claim Form Form and Instruction
10-10068a Camp Lejeune Family Member Program Claim Form 10-10068a DRAFT CLFM Claim Form 032614.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Camp Lejeune Family Member Program Claim Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10068a	Camp Lejeune Family Member Program Claim Form	10-10068a DRAFT CLFM Claim Form 032614.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,629	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	17,919	17,919
Annual IC Time Burden (Hours)	4,480	4,480
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.