Va Form 10 10068 – Fill Out and Use This PDF

OMB Number 2900-0822

Est. Burden: 30 minutes

Expiration Date: March 31, 2015

Department of Veterans Affairs

Camp Lejeune Family Member Program Application

Important! For expedited processing, please submit your application online at:

https://www.clfamilymembers.fsc.va.gov/ or for standard processing, mail the completed form to: Department of Veterans Affairs, Financial Services Center, PO Box 149200, Austin, TX 78714-9200

If you reside outside the United States enter address below

Email Address						Gender
						Male		Female
Please indicate if you would like to receive correspondence via				email	regular mail
Phone Number (include area code)				Alternate Phone Number (include area code) (optional)
Relationship to the Veteran during the period August 1, 1953 through December 31, 1987:
		Spouse	Child		Stepchild
		(provide a copy of marriage certificate)	(provide a copy of birth certificate)		(provide a copy of birth certificate)
		Legal Dependent - state your relationship (provide documentation of relationship):
			2. Residency Information
Did you reside on Camp Lejeune for 30 days or more between August 1, 1953 and December 31, 1987?								Yes	No
Dates resided on Camp Lejeune:
From (MM/YYYY)			To (MM/YYYY)
Address (if known) on Camp Lejeune:

Do you have documentation verifying your residency on Camp Lejeune?

Yes

No

If yes, please enclose a copy of the documentation with your application. Documentation may include a utility bill, pay stub, tax forms, or similar documentation.

3. Conditions/Illnesses

Have you been diagnosed with any of the following conditions?

The following conditions/illnesses may be related to your exposure to contaminated water at Camp Lejeune while living there for at least thirty days between August 1, 1953-December 31, 1987. Please check the box for any condition for which you have received a diagnosis (you do not need to have been previously diagnosed to be eligible).

Bladder cancer	Leukemia		Scleroderma	Female infertility* Dates
Breast cancer	Multiple myeloma		Renal toxicity	Miscarriage* Dates
Esophageal cancer	Myelodysplastic syndrome		Hepatic steatosis
Kidney cancer	Non-Hodgkin's lymphoma		Neurobehavioral effects
Lung cancer

*Please indicate the dates of Miscarriage and Female Infertility.

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4. Health Care Coverage

Do you have health care coverage?	Yes		No	If yes, select your type of coverage below.

Note: This includes coverage you may have through an employer, spouse, significant other or federal/state health care benefit plan. Health care coverage may also be referred to as health care insurance.

			Medicare Part A	Effective Date (MMDDYYYY)
			Medicare Part B	Effective Date (MMDDYYYY)
			Medicare Advantage	Effective Date (MMDDYYYY)
			Medicare Part D	Effective Date (MMDDYYYY)
			Medicaid/State Assistance	Effective Date (MMDDYYYY)
			TRICARE	Effective Date (MMDDYYYY)
			CHAMPVA	Effective Date (MMDDYYYY)

Please complete the following if you have other health care coverage not identified above.

Does your health care coverage provide Pharmacy benefits? Yes

No

5 Veteran Information

Last Name	First Name					MI
Social Security Number (optional)	Phone Number (include area code)
Date of Birth (MMDDYYYY)	Is Veteran deceased?		Gender
	Yes	No		Male	Female

Rank(s)

6. Certification

I hereby apply to the Camp Lejeune Family Member (CLFM) Program and give permission for my personal information to be used by appropriate Federal Government agencies, Federal Government contractors and other Government entities to determine if I am eligible for the CLFM Program.

By my signature I attest that I have answered the questions truthfully and that I understand the following: Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to gain enrollment in the CLFM Program to which that person is not entitled is subject to civil and/or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both.

I certify that the above information is correct and true to the best of my knowledge and belief. (Sign and date below.)

Signature

Date

If certification is signed by a person other than an applicant, complete the following:

Mailing Address

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Should you apply for the Camp Lejeune Family Member Program?

NOTE TO APPLICANT: You're applying to the Department of Veterans Affairs (VA). VA will consider the information you provide on this questionnaire as part of their eligibility determination for this program. Complete the form to the best of your knowledge and ability in order to establish your eligibility for this program. This program's eligibility criteria will be determined through the VA. Submission of this application does not guarantee acceptance into this program.

Getting Started: Directions for Applicant, representative or Power of Attorney (POA), please answer all questions.

Applicant Information: Please complete and provide copy of legal documents.

Residency Information: Please answer all questions. If possible, provide copies of documents verifying your residency.

Conditions/Illnesses: Please answer all questions. If you mark the box for Yes, check all the conditions you have been diagnosed with. A Treating Physician Report form is enclosed for your physician to complete and return with this application. If you mark the box for No, you may go to the next section.

Health Care Coverage: Please answer all questions and provide your health care coverage, if applicable. (Note: Health care coverage may also be referred to as health care insurance).

Veteran Information: Please answer all questions, if known.

Certification: Please sign, and date.

For more information go to: www.publichealth.va.gov/exposures/camp-lejeune/index.asp

Customer Service Center: 1-866-372-1144, Fax 512-460-5536

Camp Lejeune Family Member Program

Department of Veterans Affairs, Financial Services Center

PO Box 149200, Austin, TX 78714-9200

The Paperwork Reduction Act: This information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. The purpose of this data collection is to determine eligibility for benefits.

Privacy Act Information: The authority for collection of the requested information on this form is 38 USC 1787. The purpose of collecting this information is to determine your eligibility for reimbursement of health care related to conditions determined to result from contaminated water while you resided at Camp Lejeune, North Carolina, for a period of at least 30 days. The information you provide may be verified by computer matching programs with authoritative sources such as the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), Department of Defense (DoD), Defense Enrollment Eligibility Reporting System (DEERS), Centers for Medicare & Medicaid Services (CMS) or any other applicable authoritative source at any time. You are requested to provide your social security number as your VA record is filed and retrieved by this number. You do not have to provide the requested information on this form but if any or all of the requested information is not provided, given the form's purpose of establishing eligibility for the Camp Lejeune Family Member Program, it may delay or result in denial of your request for Camp Lejeune Family Member Program benefits. Failure to furnish the requested information will have no adverse impact on any other VA benefit to which you may be entitled. The responses you submit are considered private confidential and may be disclosed outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records number 23VA16. For example, information including your social security number may be disclosed to the Department of Defense, contractors, trading partners, health care providers and other suppliers of health care services to determine your eligibility for medical benefits and payment for services.

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