Va Form 10-10sh - State Home Program Application For Veteran Care Medical Certification Page 3
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3OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
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. The information requested on this form is solicited under the
authority of Title 38, U.S.C., Sections 1741, 1742 and 1743. It is being collected to enable us to determine your eligibility for
medical benefits in the State Home Program and will be used for that purpose. The income and eligibility you supply may be
verified through a computer matching program at any time and information may be disclosed outside the VA as permitted by
law; possible disclosures include those described in the "routine uses" identified in the VA system of records 24VA136,
Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act of 1974. Disclosure is
voluntary; however, the information is required in order for us to determine your eligibility for the medical benefit for which
you have applied. Failure to furnish the information will have no adverse affect on any other benefits to which you may be
entitled. Disclosure of Social Security number(s) of those for whom benefits are claimed is requested under the authority of
Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the administration of veterans benefits, in the
identification of veterans or persons claiming or receiving VA benefits and their records and may be used for other purposes
where authorized by Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.
VA FORM
10-10SH
APR 2009
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