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pdfINSTRUCTIONS FOR COMPLETING APPLICATION FOR THE PROGRAM
OF COMPREHENSIVE ASSISTANCE FOR FAMILY CAREGIVERS
Please Read Before You Start...
What is VA Form 10-10CG used for?
This form is used to apply for VA's Program of Comprehensive Assistance for Family Caregivers (PCAFC). VA will use the information on this form
to assist in determining your eligibility. A Veteran, as defined herein, may appoint one (1) Primary Family Caregiver applicant and up to two (2)
Secondary Family Caregiver applicants. On average, it will take 15 minutes to complete the application, including the time it will take you to read the
instructions, gather the necessary facts and fill out the form. Each time a new Primary or Secondary Family Caregiver is requested, a new Form
10-10CG is required. This includes a caregiver who is already approved and designated as a Primary Family Caregiver and wishes to be designated
as a Secondary Family Caregiver, or a caregiver who is already approved and designated as a Secondary Family Caregiver who wishes to apply as
a Primary Family Caregiver
Where can I get help filling out the form and answers to questions?
You may use ANY of the following to request assistance:
• Ask VA to help you fill out the form by calling the Caregiver Support Line at 1-855-260-3274.
• Access VA's website at http://www.va.gov and select "Contact Us".
• Locate and contact the Caregiver Support Team at your nearest VA health care facility using the team locator available at
http://www.caregiver.va.gov/.
• Contact a Veterans Service Organization.
Definitions - For purposes of this form, the following apply:
Facility Caregiver Support Program (CSP) Staff:
VA medical facility CSP Program Manager and all PCAFC and Program of General Caregiver Support Services (PGCSS) Staff at the VA medical
facility. Facility CSP Staff connect caregivers of Veterans with VA and community resources offering supportive programs and services. Facility CSP
Staff are located at every VA medical center and are designated specialists in caregiving issues.
Eligible Veteran:
A Veteran found eligible for PCAFC under 38 CFR 71.20.
Family Caregiver:
An individual who is approved and designated by VA as a Primary Family Caregiver or Secondary Family Caregiver.
Representative:
A person who has authority to act on behalf of the Veteran or who is legally vested with the responsibility or care of the Veteran. Evidence should be
submitted with this form to establish a person's status as Representative. Such evidence may be a valid power of attorney, legal guardianship order,
or similar legal documentation; or VA Form 21-0972, VA Form 21-22 or VA Form 21-22a.
Veteran:
An individual who meets the definition of Veteran in 38 U.S.C. 101(2), or a qualifying service member undergoing medical discharge from the
Armed Forces for whom a date of medical discharge has been issued, who applies for or participates in PCAFC.
VA FORM
MAY 2024
10-10CG
Page 1 of 6
Getting Started:
Please complete all fields on the form for each applicant, including signatures and dates. If you do not complete all fields, it may result in a delay or
denial of PCAFC benefits. If the Veteran applicant is not enrolled in VA's health care system or is currently a service member undergoing medical
discharge, the Veteran can submit VA Form 10-10EZ "Application for Health Benefits" with this form. Enrolled Veterans may submit VA Form
10-10EZR "Health Benefits Update Form" with this form to provide information updates.
A Representative may sign this application on behalf of a Veteran or Family Caregiver applicant; however, supporting documentation should be
provided with this application reflecting the Representative's authority to do so.
SECTION I – VETERAN
Directions for Section I - Veteran, please complete all fields, including signature and date. Use the Veteran's legal name, such as what is on a driver's
license or social security card.
SECTION II – PRIMARY FAMILY CAREGIVER APPLICANT
Directions for Section II - Primary Family Caregiver applicant, please complete all fields including signature and date. Use the applicant's legal name,
such as what is on a driver's license or social security card. An eligible Veteran may appoint one Primary Family Caregiver applicant and/or up to two
Secondary Family Caregiver applicants. If an eligible Veteran elects to only appoint a Primary Family Caregiver, then only Sections I and II must be
completed.
SECTION III – SECONDARY FAMILY CAREGIVER APPLICANT(S)
Directions for Section III - Secondary Family Caregiver applicant(s), please complete all fields including signature and date. Use the applicant's legal
name, such as what is on a driver's license or social security card. A Veteran may appoint one Primary Family Caregiver applicant and/or up to two
Secondary Family Caregiver applicants. If a Veteran elects to only appoint the Secondary Family Caregiver(s), only Sections I and III must be
completed.
Submitting your application:
1. You may apply for PCAFC online! This is the fastest way to submit your application. To apply online, please visit
https://www.va.gov/family-member-benefits/comprehensive-assistance-for-family-caregivers.
2. You may also fill out this paper form and submit your application in person or by mail by completing the following steps:
a. Read the Paperwork Reduction Act and Privacy Act Information.
b. Ensure all required fields [those designated with an asterisk (*)] are completed, including signatures and dates for each applicant. Missing
information may result in a delay or denial of PCAFC benefits.
c. Mail the completed form to the address below or submit the form to Facility CSP Staff via the Caregiver Support Line at 1-855-260-3274 or go to
https://www.caregiver.va.gov and use the Find Your Caregiver Support Team feature.
3. If a representative is signing this form on behalf of an applicant, supporting documentation should be provided at the time of application.
Submit application to:
10-10CG Evidence Intake Center
PO Box 5154
Janesville, WI 53547-5154
What happens next?
Once VA receives your application, a member of the Facility CSP Staff will contact you to review your application and discuss next steps. Veterans
who do not meet the requirements for PCAFC may be eligible for other VA health benefits and other caregiver support services. To learn about other
caregiver support services, contact your Facility CSP Staff via the Caregiver Support Line at 1-855-260-3274 or go to http://www.caregiver.va.gov/
and use the Find Your Caregiver Support Team option.
THE PAPERWORK REDUCTION ACT
This information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of
information is estimated to average 15 minutes per response, including the time to read instructions, gather necessary data, and fill out the form. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB
control number. Completion of this form is mandatory for individuals who wish to participate in the Program of Comprehensive Assistance for Family Caregivers.
PRIVACY ACT INFORMATION
VA is asking you to provide the information on this form under 38 U.S.C. Sections 101, 5303A, 1705, 1710, 1720B, 1720G, 1725 and 1781 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, “Patient Medical Records --VA” (24VA10A7), “Enrollment and Eligibility
Records --VA” (147VA10), and “Veterans and Beneficiaries Purchased Care Community Health Care Claims, Correspondence, Eligibility, Inquiry and Payment Files VA” (54VA10NB3), Caregiver Support Program - Caregiver Record Management Application (CARMA) - VA (197VA10) and in accordance with the VHA Notice of Privacy Practices.
Records in CARMA are used to administer, monitor and track services and benefits sought and delivered through VA's Caregiver Support Program. Veteran and Family Caregiver
Applicants each have their own individual records within CARMA. Providing the requested information, including Social Security Number, is voluntary, but if any requested information
is not provided, it may delay or result in denial of the 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, and for other purposes authorized or required by law.
VA FORM 10-10CG, MAY 2024
Page 2 of 6
Estimated Burden: 15 min.
OMB Number 2900-0768
Expiration Date: 01/31/2027
APPLICATION FOR THE PROGRAM OF COMPREHENSIVE
ASSISTANCE FOR FAMILY CAREGIVERS
ATTENTION: Complete the application and mail it to 10-10CG Evidence Intake Center, PO Box 5154, Janesville, WI 53547-5154. You may also mail or hand carry it to
your Facility CSP Staff for processing. Individuals may apply online at https://www.va.gov/family-member-benefits/comprehensive-assistance-for-family-caregivers. VA does
not provide the Program of Comprehensive Assistance for Family Caregivers to individuals residing outside the 50 states, the District of Columbia, and the U.S. Territories.
SECTION I - VETERAN
1. Last Name*
2. First Name*
5. Social Security Number/Tax Identification Number (999-99-9999)
6. Date of Birth (MM/DD/YYYY)*
8. Current Street Address (where you reside, not a PO Box)*
9. City*
10. County*
13. Primary Telephone Number (Including Area Code)(999-999-9999)*
4. Suffix
3. Middle Name
7. Birth Sex
Male
Female
12. Zip Code (99999-9999)*
11. State*
14. Alternate Telephone Number (Including Area Code) (999-999-9999)
15. Email Address
16. Name of VA medical center or clinic where you receive or plan to receive health care services*
Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims.
I certify that the individual(s) named in this application are involved in my care and I consent to sharing information necessary to their involvement in my
health care, payment related to such health care or as needed for notification purposes. I certify that the information provided in this form is correct and true
to the best of my knowledge and belief.
17. Veteran or Representative Signature*
VA FORM 10-10CG, MAY 2024
18. Date (MM/DD/YYYY)*
Page 3 of 6
SECTION II - PRIMARY FAMILY CAREGIVER APPLICANT
1. Last Name*
2. First Name*
5. Social Security Number/Tax Identification Number (999-99-9999)
6. Date of Birth (MM/DD/YYYY)*
8. Current Street Address (where you reside, not a PO Box)*
9. City*
10. County*
4. Suffix
3. Middle Name
7. Birth Sex
Male
Female
11. State*
12. Zip Code (99999-9999)*
16. State
17. Zip Code (99999-9999)
13. Mailing Address, if different from Street Address
14. City
15. County
18. Primary Telephone Number (Including Area Code)(999-999-9999)*
19. Alternate Telephone Number (Including Area Code) (999-999-9999)
20. Email Address
21. Relationship to Veteran (e.g., Spouse, Parent, Son, Daughter,
Grandchild, Other)*
Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims.
I certify that I am at least 18 years of age.
I certify that either: (1) I am a member of the Veteran's family (including a parent, spouse, a son or daughter, a step-family member, or an extended family
member) OR (2) I am not a member of the Veteran's family, and I reside with the Veteran full-time or will do so upon designation as the Veteran's Primary
Family Caregiver.
I attest that my application and/or participation in PCAFC is as the Veteran's Family Caregiver. I acknowledge my eligibility for any payment and/or other
benefit that results is contingent on the Veteran's eligibility and participation and as such the Veteran is involved in my payment related activities.
I agree to perform personal care services as the Primary Family Caregiver for the Veteran named on this application.
I understand that the Veteran or the Veteran's surrogate may request my discharge from the Program of Comprehensive Assistance for Family Caregivers
(PCAFC) at any time and that my designation as a Primary Family Caregiver may be revoked or I may be discharged from PCAFC by the Secretary of
Veterans Affairs (or designee) as set forth in 38 CFR 71.45.
I understand that participation in the PCAFC does not create an employment relationship between me and the Department of Veterans Affairs.
I certify that the information provided in this form is correct and true to the best of my knowledge and belief.
22. Primary Family Caregiver Applicant Signature*
VA FORM 10-10CG, MAY 2024
23. Date (MM/DD/YYYY)*
Page 4 of 6
SECTION III - SECONDARY FAMILY CAREGIVER APPLICANT
(Complete if appointing a Secondary Family Caregiver Applicant)
1. Last Name*
2. First Name*
5. Social Security Number/Tax Identification Number (999-99-9999)
6. Date of Birth (MM/DD/YYYY)*
8. Current Street Address (where you reside, not a PO Box)*
9. City*
10. County*
4. Suffix
3. Middle Name
7. Birth Sex
Male
Female
11. State*
12. Zip Code (99999-9999)*
16. State
17. Zip Code (99999-9999)
13. Mailing Address, if different from Street Address
14. City
15. County
18. Primary Telephone Number (Including Area Code)(999-999-9999)*
19. Alternate Telephone Number (Including Area Code) (999-999-9999)
20. Email Address
21. Relationship to Veteran (e.g., Spouse, Parent, Son, Daughter,
Grandchild, Other)*
Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims.
I certify that I am at least 18 years of age.
I certify that either: (1) I am a member of the Veteran's family (including a parent, spouse, a son or daughter, a step-family member, or an extended family
member) OR (2) I am not a member of the Veteran's family, and I reside with the Veteran full-time or will do so upon designation as the Veteran's Primary
Family Caregiver.
I attest that my application and/or participation in PCAFC is as the Veteran's Family Caregiver. I acknowledge my eligibility for any payment and/or other
benefit that results is contingent on the Veteran's eligibility and participation and as such the Veteran is involved in my payment related activities.
I agree to perform personal care services as the Primary Family Caregiver for the Veteran named on this application.
I understand that the Veteran or the Veteran's surrogate may request my discharge from the Program of Comprehensive Assistance for Family Caregivers
(PCAFC) at any time and that my designation as a Primary Family Caregiver may be revoked or I may be discharged from PCAFC by the Secretary of
Veterans Affairs (or designee) as set forth in 38 CFR 71.45.
I understand that participation in the PCAFC does not create an employment relationship between me and the Department of Veterans Affairs.
I certify that the information provided in this form is correct and true to the best of my knowledge and belief.
22. Secondary Family Caregiver Applicant Signature*
VA FORM 10-10CG, MAY 2024
23. Date (MM/DD/YYYY)*
Page 5 of 6
SECTION III - SECONDARY FAMILY CAREGIVER APPLICANT (Continued)
(Complete if appointing more than one Secondary Family Caregiver Applicant)
1. Last Name*
2. First Name*
5. Social Security Number/Tax Identification Number (999-99-9999)
6. Date of Birth (MM/DD/YYYY)*
8. Current Street Address (where you reside, not a PO Box)*
9. City*
10. County*
4. Suffix
3. Middle Name
7. Birth Sex
Male
Female
11. State*
12. Zip Code (99999-9999)*
16. State
17. Zip Code (99999-9999)
13. Mailing Address, if different from Street Address
14. City
15. County
18. Primary Telephone Number (Including Area Code)(999-999-9999)*
19. Alternate Telephone Number (Including Area Code) (999-999-9999)
20. Email Address
21. Relationship to Veteran (e.g., Spouse, Parent, Son, Daughter,
Grandchild, Other)*
Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims.
I certify that I am at least 18 years of age.
I certify that either: (1) I am a member of the Veteran's family (including a parent, spouse, a son or daughter, a step-family member, or an extended family
member) OR (2) I am not a member of the Veteran's family, and I reside with the Veteran full-time or will do so upon designation as the Veteran's Primary
Family Caregiver.
I attest that my application and/or participation in PCAFC is as the Veteran's Family Caregiver. I acknowledge my eligibility for any payment and/or other
benefit that results is contingent on the Veteran's eligibility and participation and as such the Veteran is involved in my payment related activities.
I agree to perform personal care services as the Primary Family Caregiver for the Veteran named on this application.
I understand that the Veteran or the Veteran's surrogate may request my discharge from the Program of Comprehensive Assistance for Family Caregivers
(PCAFC) at any time and that my designation as a Primary Family Caregiver may be revoked or I may be discharged from PCAFC by the Secretary of
Veterans Affairs (or designee) as set forth in 38 CFR 71.45.
I understand that participation in the PCAFC does not create an employment relationship between me and the Department of Veterans Affairs.
I certify that the information provided in this form is correct and true to the best of my knowledge and belief.
22. Secondary Family Caregiver Applicant Signature*
VA FORM 10-10CG, MAY 2024
23. Date (MM/DD/YYYY)*
Page 6 of 6
| File Type | application/pdf |
| File Title | VA Form 10-10CG |
| Subject | Application for the Program of Comprehensive Assistance for Family Caregivers. |
| Author | Department of Veterans Affairs |
| File Modified | 2024-08-22 |
| File Created | 2024-08-22 |