OMB Number: 2900-0629-2025

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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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What is VA form 10 10EC used for?

To determine the estimated amount of your monthly copayment obligations for extended care services provided to you by VA, either directly by VA or paid for by VA. There is no copayment for the first 21 days of extended care services that VA provides to you in any 12 month period.

What is the purpose of form 10 10EZ?

Use VA Form 10-10EZ if youre a Veteran and want to apply for VA health care. You must be enrolled in VA health care to get care at VA health facilities or to have us cover your care at a community care provider (an approved non-VA provider).

What is OMB approved no 2900 0043?

OMB 2900-0043 VA Form 21-686c is used to obtain current information about marital status and dependent child(ren). The information is needed to determine the correct rate of payment for veterans and beneficiaries who may be entitled to an additional allowance for dependents or to remove dependents.

What is the OMB number on my tax return?

OMB Numbers are form and information collection numbers assigned by The Office of Management and Budget. The Office of Management and Budget is the largest office within the Executive Office of the President of the United States. The OMB generates these Control Numbers under the Paperwork Reduction Act of 1980.