Waiver Statement

Health Eligibility Center (HEC) Income Verification (IV) Forms

Documents and Forms

Document Name Document Type
Form 10-304 Waiver Statement Form and Instruction
10-304 Waiver Statement VA Form 10-304.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Waiver Statement	Agency IC Tracking Number:	2900-0867

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	10-304	Waiver Statement	VA Form 10-304.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 44,008	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	44,008	44,008
Annual IC Time Burden (Hours)	14,669	14,669
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.