10-10HS VA Request for Hardship Determination

OMB Approved No. 2900-0091
Estimated Burden Avg. 15 min
Expiration Date: 06/30/2024

REQUEST FOR HARDSHIP DETERMINATION
The Request for Hardship Determination form is used to determine whether the veteran's projected income for the current year will be substantially below
the VA means test threshold due to a loss of income or increase in allowable deductible expenses. Veterans determined to have a financial hardship will be
exempt from payment of hospital and medical care copays and qualify for enrollment in Priority Group 5, unless otherwise eligible for enrollment in a
higher priority, from the date of request through the last day of the same calendar year.
1. VETERAN'S NAME (Last, First, Middle Name)

GENERAL INFORMATION
2. SOCIAL SECURITY NUMBER

3D. COUNTY

3B. STATE 3C. ZIP CODE (9 digits)

3A. CITY

3. PERMANENT ADDRESS (Street)

3E. HOME TELEPHONE NUMBER (Include area code)

3F. CELLULAR TELEPHONE NUMBER (Include area code)

REASON/CIRCUMSTANCE FOR HARDSHIP REQUEST (Check all that apply and add explanation as needed below)
Reduction of household income

Paid out of pocket medical expenses

Moved to a higher cost of living area

Other - explain below

Increase in number of dependents

Provide explanation, as needed, and attach documentation supporting your request.

PROJECTED HOUSEHOLD INCOME AND DEDUCTIBLE EXPENSES FOR THE CURRENT CALENDAR YEAR
Veteran

Spouse

Children

1. HOUSEHOLD INCOME (Includes gross income from employment,

net income from farm or ranch, and other income amounts.)

2. DEDUCTIBLE EXPENSES (Includes non-reimbursed medical

expenses paid by you or your spouse, funeral and burial expenses
and expenses for the veteran's education.)
VA BURDEN STATEMENT AND PRIVACY ACT INFORMATION
VA Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays
a currently valid OMB control number. The OMB control number for this project is 2900-0091, and it expires 06/30/2024. Public reporting burden for this
collection of information is estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at
VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0091 in any correspondence. Do not send your completed VA Form
10-10HS to this email address.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1705, 1710, 1712, and 1722 in order for
VA to determine your eligibility for medical benefits. Information you supply may be verified through a computer-matching program. VA may disclose
the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act
systems of records notices and in accordance with the VHA Notice of Privacy Practices. Providing the requested information is voluntary, but if any or all
of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will
not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer
your VA benefits. VA may also use this information to identify veterans and persons claiming or receiving VA benefits and their records.
SIGNATURE AND DATE
VETERAN'S SIGNATURE

DATE (MM/DD/YYYY)

PENALTY: The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a
material fact, knowing it to be false.

VA FORM
MAR 2024

10-10HS

HEC

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HARDSHIP DETERMINATION (to be completed by VA)
Hardship Granted: (check one)
YES - Hardship is granted
Note: The exemption is effective from the date the Veteran submitted the request until the last day of the calendar year in which the request
was made.
NO. State reason not granted in comments.
Date Veteran's electronic record updated in VA's information system (MM/DD/YYYY):
DATE (MM/DD/YYYY)

VHA STAFF SIGNATURE

COMMENTS
Document and/or attach any pertinent information impacting on the final decision.

VETERAN NOTIFICATION
Date Veteran notified (MM/DD/YYYY):
If hardship not granted, provide Veteran with VA Form 10-0998, Your Rights To Seek Further Review Of Our Health Care Benefits Decision.
VA FORM 10-10HS, MAR 2024

HEC

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