Form 10-2407 Residential Care Home Program Sponsor Application

OMB Number: 2900-0491
Estimated Burden: 5 minutes
Expiration Date: XX/XX/20XX

RESIDENTIAL CARE HOME PROGRAM
SPONSOR APPLICATION

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 number. The OMB control number for this project is 2900-0491, and it expires XX/XX/20XX. Public reporting
burden for this collection of information is estimated to average 5 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 or any other aspect of this collection, including suggestions for reducing the burden to VA Reports
Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0491 in any correspondence. Do not send your
completed VA Form 10-2407 to this email address.
Privacy Act Notice: The information requested on this form is solicited under authority of 38 United States Code 630, and will be used to evaluate
the suitability of the home for participation in the Residential Care Program. Information is stored in a System of Records - "Community Residential
Care and Medical Foster Home Program-VA" (142VA10). It may be disclosed outside VA as permitted by law or as stated in the "Notices of
Systems of VA Records," which have been published in the Federal Register in accordance with the Privacy Act of 1974.
The VA Residential Care Program provides room, board, and limited personal care and supervision to veterans who do not require hospital or
nursing home care but because of medical or psychosocial health conditions are not able to live independently and have no suitable family resources
to provide the needed care. Care is provided at the veteran's own expense in private homes inspected by VA. The veteran receives monthly follow-up
visits from VA social workers and other health care professionals. If you wish to apply to become a sponsor in the Residential Care Home Program,
please complete items 2 through 6 below.
1. VA FACILITY (For VA use Only)

2. APPLICANT INFORMATION
2B. TELEPHONE NUMBER

2A. NAME (Last, first, middle initial)

2C. ADDRESS (Number and Street or Rural Route, City, State and ZIP Code)

3. REFERENCES (List four references, including two neighbors)
A. NAME

B. ADDRESS

C. TELEPHONE NUMBER

(Neighbor)

(Neighbor)

4. In making application, I agree to:

a. An initial inspection of my home by a health care team from VA facility and an annual inspection thereafter.
b. Authorize VA to contact other agencies regarding the suitability of my home for residential care.
c. Comply with VA standards for residential care.
d. Accept veterans without discrimination on the basis of race, color, sex, age, religion or national origin.
e. Accept the agreed-upon monthly rate as full compensation for care given.

5. SIGNATURE OF APPLICANT

VA FORM SEP 2024

10-2407

6. DATE