Application for Extended Care Services

Application for Extended Care Services, VA Form 10-10EC

Documents and Forms

Document Name Document Type
Form 10-10EC Application for Extended Care Services Form and Instruction
10-10EC Application for Extended Care Benefits VA Form 10-10EC_Application for Extended Care Services_updated 2019.pdf Form and Instruction
10-10EC Application for Extended Care Benefits VA Form 10-10EC_Application for Extended Care Services_updated 2019.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Application for Extended Care Services	Agency IC Tracking Number:	2900-0629

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 1.46

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10EC	Application for Extended Care Benefits	VA Form 10-10EC_Application for Extended Care Services_updated 2019.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	3,000	3,000
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.