OMB Number: 2900-0629-2026

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The document provides detailed instructions for veterans on how to complete the VA Form 10-10EC, which is used to apply for extended care services from the Department of Veterans Affairs (VA). It outlines eligibility criteria, necessary information required for the application, and steps for completion, including sections on general information, insurance details, spousal and dependent information, income and asset reporting, and expenses. The document also emphasizes the importance of providing accurate financial data to determine copayment obligations and offers guidance on where to seek assistance in filling out the form.

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Click ‘Get Form’ to open the OMB Number: 2900-0629 in the editor.
Begin with Section I - General Information. Enter your full name and Social Security number accurately.
Proceed to Section II - Insurance Information. Provide details for Medicare and any other health insurance coverage, ensuring you include copies of relevant cards.
In Section III - Spouse/Dependent Information, list all applicable details about your spouse and dependents, including their Social Security numbers and current residency status.
Move to Section IV - Fixed and Liquid Assets. Report your financial assets as instructed, noting which assets are excluded based on your care type.
Complete Section VI - Current Gross Income of Veteran and Spouse by detailing all income sources, ensuring accuracy for proper copayment assessment.
Finalize by signing Sections VIII, IX, and X. Attach necessary documentation before submitting your application to the designated VA personnel.

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