Form 10-5588 - State Home Report And Statement Of Federal Aid Claimed - Department Of Veterans Affairs Page 5

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STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED CONTINUED
TOTAL STATE OPERATING BEDS AT END OF THE MONTH
DOMICILIARY CARE
NURSING HOME CARE
HOSPITAL CARE
ADULT DAY HEALTH CARE
I certify that this report is correct, that all residents included in the report were physically present during the period
for which Federal aid is claimed, except for authorized absences, and that facility management has complied with all
provisions of Title VI, Public Law 88-352, entitled Civil Rights Act of 1964.
SIGNATURE OF STATE HOME ADMINISTRATOR
DATE
SIGNATURE OF STATE EMPLOYEE WHEN APPLICABLE
DATE
REMARKS
The Paperwork Reduction Act of 1995
requires us to notify you that this information collection is in
accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not
conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB
number. We anticipate that the time expended by all individuals who must complete this form will average 30
minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
Although completion of this form is voluntary, VA will be unable to provide reimbursement for services rendered
without a completed form. Failure to complete the form will have no effect on any other benefits to which you may
be entitled. This information is collected under the authority of Title 38 CFR Parts 51 and 52.
10-5588
Page 5 of 5
VA FORM
MAY 2009

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