SECTION III - SECONDARY FAMILY CAREGIVER (Continued)
I certify that I am at least 18 years of age.
Check one:
I certify that I am a family member of the Veteran or Servicemember named in this application.
OR
I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval.
I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this
application.
I understand that the Veteran may revoke my designation as Secondary Family Caregiver at any time and that the Secretary of
the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the
Program requirements as defined by law.
I certify that the information above is correct and true to the best of my knowledge and belief.
Date
Secondary Family Caregiver Signature
SECONDARY FAMILY CAREGIVER - Complete if appointing more than one Secondary Caregiver.
Last Name
First Name
Middle Name
Gender
Social Security Number
Date of Birth (mm-dd-yyyy)
Male
Female
Current Street Address
City
State
Zip Code
Telephone Number (Including Area Code)
Cell Number (Including Area Code)
Email Address
Relationship to Veteran (e.g., Spouse, Parent, Child, Other)
Federal Laws (18 USC 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.
Check one:
I certify that I am a family member of the Veteran or Servicemember named in this application.
OR
I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval.
I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this
application.
I understand that the Veteran may revoke my designation as Secondary Family Caregiver at any time and that the Secretary
of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the
Program requirements as defined by law.
I certify that the information above is correct and true to the best of my knowledge and belief.
Date
Secondary Family Caregiver Signature
10-10CG
VA FORM
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April 2016
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