VA 10-10D 2023 free printable template

VA FORM JUL 2014 10-10d injury was incurred or aggravated while on active duty in military service and resulted in some degree of disability. If certification is signed by a person other than an applicant complete the following X VA FORM JUL 2014 10-10d Date SUPERSEDES VA FORM 10-10D JUN 2010 WHICH WILL NOT BE USED State Zip Code Page 2 of 3 Notice Termination of marriage by divorce or annulment to the qualifying sponsor ends CHAMPVA eligibility as of midnight on the effective date of the...dissolution of marriage. OMB Number 2900-0219 Estimated Burden 10 minutes Expiration Date 01/31/2017 Application for CHAMPVA Benefits Chief Business Office Purchased Care CHAMPVA Eligibility PO Box 469028 Denver CO 80246-9028 Customer Service Center 1-800-733-8387 FAX 303-331-7809 Attention Please review the instructions on the reverse side and then complete this form in its entirety print or type only. Return the form and any additional requested information to the address shown above. If...applicants indicate in Section II that they have Medicare or Other Health Insurance each applicant must submit a VA Form 10-7959c. If additional space is needed complete another 10-10d Veteran s Last Name Section I - Sponsor Information MI Social Security Number VA File Number Claim Number First Name City Street Address Telephone Number include area code State Zip Code Date of Birth mm-dd-yyyy Date of Marriage mm-dd-yyyy Date of Death mm-dd-yyyy Did veteran die while Yes Yes If yes on active...military service If no go to sect. II No Section II - Applicant Information if necessary continue on additional 10-10d and complete in its entirety Last Name Male Sex Female Is veteran deceased Email Address include area code Date of Birth Enrolled in mm-dd-yyyy Medicare Yes Other Health No Insurance If yes complete VA Form 10-7959c and attach a copy of Medicare Card Yes Relationship to the veteran No i.e. spouse child stepchild Insurance card Section III - Certification Federal Laws 18 USC 287...and 1001 provide for criminal penalties for knowingly submitting false fictitious or fraudulent statements or claims I declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. In order to extend CHAMPVA benefits to students age 18 to 23 school certification of full-time enrollment must be submitted by the college vocational or high school etc. Student status for CHAMPVA purposes is established up to a full school term based on the initial enrollment...letter from the accredited education institution that is four years 4 for traditional schooling programs two years 2 for technical schooling programs. School certification for each term or a full year is required for normal beginning and ending school year. Student s full name Student s Social Security number SSN Exact beginning date and projected graduation date Number of semester hours or equivalent high schools excluded School generated forms are acceptable as long as they provide the above...information. While translation. Certifications may be submitted by mail to the address on the front or by FAX NOTE It is important to notify the Chief Business Office Purchased Care of any change in student status such as withdrawal or change from full-time to part-time status. Student s full name Student s Social Security number SSN Exact beginning date and projected graduation date Number of semester hours or equivalent high schools excluded School generated forms are acceptable as long as...they provide the above information. While translation. Certifications may be submitted by mail to the address on the front or by FAX NOTE It is important to notify the Chief Business Office Purchased Care of any change in student status such as withdrawal or change from full-time to part-time status. School vacation periods holidays and summer breaks providing the student attends school on a full-time basis both before and after the summer break are not considered an interruption in full-time...attendance and will not create a break in CHAMPVA eligibility. The purpose of collecting this information is to determine your eligibility for CHAMPVA benefits. The information you provide may be verified by a computer matching program at any time. You are requested to provide your social security number as your VA record is filed and retrieved by this number. You do not have to provide the requested information on this form but if any or all of the requested information is not provided it may...delay or result in denial of your request for other VA benefit to which you may be entitled. The responses you submit are considered confidential and may be disclosed outside VA only if the disclosure is authorized under the Privacy Act including the routine uses identified in the VA system of records number 54VA16 titled Health Administration Center Civilian Health and Medical Program Records -VA as set forth in the Compilation of Privacy Act Issuances via online GPO access at http //www.