VA Form 10-10CG at a glance
What it is: These are the instructions for completing the Application for the Program of Comprehensive Assistance for Family Caregivers.
Who signs: Complete all fields on the form for each applicant, including signatures and dates; if you do not complete all fields, it may result in a delay or denial of PCAFC benefits. A Representative may sign this application on behalf of a Veteran or Family Caregiver applicant; however, supporting documentation should be provided with this application reflecting the Representative's authority to do so.
Where and when to file: Complete the application and mail it to 10-10CG Evidence Intake Center, PO Box 5154, Janesville, WI 53547-5154; you may also mail or hand carry it to your Facility CSP Staff for processing.
This form is used to apply for VA's Program of Comprehensive Assistance for Family Caregivers (PCAFC). VA will use the information on this form to assist in determining your eligibility. A Veteran may appoint one (1) Primary Family Caregiver applicant and up to two (2) Secondary Family Caregiver applicants. On average, it will take 15 minutes to complete the application, including the time it will take you to read the instructions, gather the necessary facts and fill out the form. Each time a new Primary or Secondary Family Caregiver is requested, a new Form 10-10CG is required. This includes a caregiver who is already approved and designated as a Primary Family Caregiver and wishes to be designated as a Secondary Family Caregiver, or a caregiver who is already approved and designated as a Secondary Family Caregiver who wishes to apply as a Primary Family Caregiver.
What to bring and attach to VA Form 10-10CG
Evidence should be submitted with this form to establish a person's status as Representative; such evidence may be a valid power of attorney, legal guardianship order, or similar legal documentation, or VA Form 21-0972, VA Form 21-22 or VA Form 21-22a.
If the Veteran applicant is not enrolled in VA's health care system or is currently a service member undergoing medical discharge, the Veteran can submit VA Form 10-10EZ "Application for Health Benefits" with this form.
Enrolled Veterans may submit VA Form 10-10EZR "Health Benefits Update Form" with this form to provide information updates.
A filled-in VA Form 10-10CG example: a Veteran completes Section I
How to fill out VA Form 10-10CG, box by box
Last Name, First Name, Middle Name and Suffix
For Section I - Veteran, complete all fields, including signature and date, and use the Veteran's legal name, such as what is on a driver's license or social security card.
Enter the Last Name, First Name, Middle Name and Suffix.
Social Security Number, Date of Birth, Sex and Current Street Address
Enter the Social Security Number/Tax Identification Number (999-99-9999) and the Date of Birth (MM/DD/YYYY).
Mark Male or Female for Sex and enter the Current Street Address (where you reside, not a PO Box), City, County, State and Zip Code (99999-9999).
Telephone Numbers, Email Address and VA medical center
Enter the Primary Telephone Number (Including Area Code)(999-999-9999) and the Alternate Telephone Number (Including Area Code) (999-999-9999).
Enter the Email Address and the Name of VA medical center or clinic where you receive or plan to receive health care services.
The Veteran's signature
By signing, you certify that the individual(s) named in this application are involved in your care and you consent to sharing information necessary to their involvement in your health care, payment related to such health care or as needed for notification purposes. By signing, you also certify that the information provided in this form is correct and true to the best of your knowledge and belief.
The Veteran or Representative signs at Veteran or Representative Signature and enters the Date (MM/DD/YYYY).
Section II - Primary Family Caregiver Applicant
For Section II - Primary Family Caregiver applicant and Section III - Secondary Family Caregiver applicant(s), complete all fields including signature and date, and use the applicant's legal name, such as what is on a driver's license or social security card.
For the Primary Family Caregiver Applicant, enter the Last Name, First Name, Middle Name and Suffix.
Enter the Social Security Number/Tax Identification Number (999-99-9999), the Date of Birth (MM/DD/YYYY), Male or Female for Sex, and the Current Street Address (where you reside, not a PO Box), City, County, State and Zip Code (99999-9999).
If the Mailing Address is different from the Street Address, enter the Mailing Address, City, County, State and Zip Code (99999-9999).
Enter the Primary Telephone Number (999-999-9999), the Alternate Telephone Number (999-999-9999), the Email Address and the Relationship to Veteran (e.g., Spouse, Parent, Son, Daughter, Grandchild, Other).
By signing, you certify that you are at least 18 years of age.
By signing, you certify that either (1) you are a member of the Veteran's family (including a parent, spouse, a son or daughter, a step-family member, or an extended family member) OR (2) you are not a member of the Veteran's family, and you reside with the Veteran full-time or will do so upon designation as the Veteran's Primary Family Caregiver.
Participation in the PCAFC does not create an employment relationship between you and the Department of Veterans Affairs.
The Primary Family Caregiver Applicant signs at Primary Family Caregiver Applicant Signature and enters the Date (MM/DD/YYYY).
Section III - Secondary Family Caregiver Applicant
Section III is completed if appointing a Secondary Family Caregiver Applicant; the continued Section III is completed if appointing more than one Secondary Family Caregiver Applicant.
For each Secondary Family Caregiver Applicant, enter the Last Name, First Name, Middle Name, Suffix, Social Security Number/Tax Identification Number (999-99-9999), Date of Birth (MM/DD/YYYY), Sex, Current Street Address (where you reside, not a PO Box), City, County, State and Zip Code (99999-9999). Enter the Mailing Address if different from Street Address, then the Primary Telephone Number, Alternate Telephone Number, Email Address and Relationship to Veteran.
The Secondary Family Caregiver Applicant signs at Secondary Family Caregiver Applicant Signature and enters the Date (MM/DD/YYYY).
More rules for VA Form 10-10CG
Ensure all required fields (those designated with an asterisk (*)) are completed, including signatures and dates for each applicant.
Other situations
The Veteran appoints only a Primary Family Caregiver
If an eligible Veteran elects to only appoint a Primary Family Caregiver, then only Sections I and II must be completed.
The Veteran appoints only Secondary Family Caregivers
If a Veteran elects to only appoint the Secondary Family Caregiver(s), only Sections I and III must be completed.
Common questions about VA Form 10-10CG
Where do I file it?
You may apply for PCAFC online at https://www.va.gov/family-member-benefits/comprehensive-assistance-for-family-caregivers, the fastest way to submit your application.
Is there a penalty?
Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims.
When is this form not the right one?
VA does not provide the Program of Comprehensive Assistance for Family Caregivers to individuals residing outside the 50 states, the District of Columbia, and the U.S. Territories. Veterans who do not meet the requirements for PCAFC may be eligible for other VA health benefits and other caregiver support services.
Where to get help with VA Form 10-10CG
You may ask VA to help you fill out the form by calling the Caregiver Support Line at 1-855-260-3274.
Sources
[1] VA Form 10-10CG (FEB 2025), Application for the Program of Comprehensive Assistance for Family Caregivers, U.S. Department of Veterans Affairs (the Official source link on this page).
