Military families have a lot to worry about, and one of the many concerns is what will happen if something happens to the service member. Va Form 10 10Cg helps military families prepare for the unthinkable. This form allows you to designate a guardian for your children in case something happens to you while you're on active duty. Knowing that your kids are taken care of if something happens to you can provide some peace of mind during difficult times. Make sure you complete Va Form 10 10Cg if you have young children and are active duty military personnel. The form can be found on the website for the Department of Veterans Affairs (VA).
Before you decide to complete va form 10 10cg, you'll want to know more about the type of form you are going to work with.
| Question | Answer |
|---|---|
| Form Name | Va Form 10 10Cg |
| Form Length | 5 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 15 sec |
| Other names |
INSTRUCTIONS FOR COMPLETING APPLICATION FOR THE PROGRAM
OF COMPREHENSIVE ASSISTANCE FOR FAMILY CAREGIVERS
Please Read Before You Start...
What is VA Form
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, as defined herein, 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
Where can I get help filling out the form and answers to questions?
You may use ANY of the following to request assistance:
•Ask VA to help you fill out the form by calling us at
•Access VA's website at http://www.va.gov and select "Contact Us".
•Locate and contact the Caregiver Support Coordinator at your nearest VA health care facility. A Caregiver Support Coordinator locator is available at http://www.caregiver.va.gov/.
•Contact the National Caregiver Support Line by calling
•Contact a Veterans Service Organization.
Definitions - For purposes of this form, the following apply:
Caregiver Support Coordinator (CSC):
A VA clinical professional who connects caregivers of Veterans with VA and community resources offering supportive programs and services. Caregiver Support Coordinators are located at every VA medical center and are designated specialists in caregiving issues.
Eligible Veteran:
Means a Veteran, as defined herein, who is found eligible under 38 CFR 71.20.
Family Caregiver:
An individual who is approved and designated by VA as a Primary Family Caregiver or Secondary Family Caregiver.
Personal Care Services:
Care or assistance of another person necessary in order to support the eligible Veteran's health and
Representative:
A person who, under applicable law, has authority to act on behalf of the Veteran or who is legally vested with the responsibility or care of the Veteran. Evidence must be submitted with this form to establish a person's legal status as Representative. Such evidence may be a valid power of attorney, legal guardianship order, or similar legal documentation or certification issued by an appropriate authority, including a Federal, State, local, or tribal law that establishes such authority.
Veteran:
An individual who meets the definition of Veteran in 38 U.S.C. 101(2), or a qualifying service member undergoing medical discharge from the Armed Forces for whom a date of medical discharge has been issued, who applies for or participates in PCAFC.
Who should apply for VA's Program of Comprehensive Assistance for Family Caregivers?
IF THE INDIVIDUAL IS A: |
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Veteran |
Has a disability rating from VA of 70% or |
Requires at least 6 |
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VA's Program of Comprehensive |
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connected disability (or disabilities), |
personal care services that |
Assistance for Family Caregivers. |
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incurred or aggravated in the line of |
are provided by a family |
Complete this form to apply. |
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duty, on, before, or after a qualifying |
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date, as set forth in 38 U.S.C. 1720G(a) |
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designated as a Family |
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Caregiver). |
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This table does not represent all of the requirements for PCAFC eligibility. Your local Caregiver Support Coordinator is available to provide additional information on eligibility.
Veterans who do not meet the requirements for PCAFC may be eligible for other VA health benefits and other caregiver support services. To learn about other caregiver support services, contact the Caregiver Support Coordinator (CSC) at your local VA health care facility. To contact your local CSC, call the Caregiver Support Line at
VA FORM |
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Getting Started:
Complete the fields on the form. Fields designated with an asterisk (*) must be completed or the application will be considered incomplete. 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
SECTION I – VETERAN
Directions for Section I - Veteran, or his/her Representative, please complete all fields (those designated with an asterisk (*) are required), sign and date.
SECTION II – PRIMARY FAMILY CAREGIVER APPLICANT
Directions for Section II - Primary Family Caregiver applicant, please complete all fields (those designated with an asterisk (*) are required) including health care coverage information, sign and date. A Veteran or his/her Representative may appoint one Primary Family Caregiver applicant, but this is not required. If a Veteran or his/her Representative elects to only appoint a Primary Family Caregiver, only Sections I and II must be completed.
SECTION III – SECONDARY FAMILY CAREGIVER APPLICANT(S)
Directions for Section III - Secondary Family Caregiver applicant(s), please complete all fields (those designated with an asterisk (*) are required), sign and date. A Veteran or his/her Representative may appoint up to two Secondary Family Caregiver applicants, but this is not required. If a Veteran or his/her Representative elects to only appoint a Secondary Family Caregiver(s), only Sections I and III must be completed.
Submitting your application:
1.Read the Paperwork Reduction Act and Privacy Act Information.
2.Ensure all required fields are completed (those designated with an asterisk (*) are required), including signatures and dates.
3.Submit the completed form to the Health Eligibility Center using the address below or submit the form to your local VA Medical Center Caregiver Support Coordinator (CSC). To contact your local CSC, you can call the Caregiver Support Line at
4.Supporting documentation reflecting the Representative's authority to complete this form on behalf of the Veteran, if applicable, must be provided. VA Form
Submit application to:
Program of Comprehensive Assistance for Family Caregivers
Health Eligibility Center
2957 Clairmont Road NE, Ste 200
Atlanta, GA
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 15 minutes per response, including the time to read instructions, gather necessary data, and fill out the form. 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. Completion of this form is mandatory for individuals who wish to participate in the Program of Comprehensive Assistance for Family Caregivers.
PRIVACY ACT INFORMATION
VA is asking you to provide the information on this form under 38 U.S.C. Sections 101, 5303A, 1705, 1710, 1720B, 1720G, 1725 and 1781 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a
VA FORM |
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Estimated Burden: 15 min.
OMB Number
Expiration Date: 04/30/2024
APPLICATION FOR THE PROGRAM OF COMPREHENSIVE
ASSISTANCE FOR FAMILY CAREGIVERS
Attention: Complete the application and mail it to Program of Comprehensive Assistance for Family Caregivers, Health Eligibility Center, 2957 Clairmont Road NE, Ste 200, Atlanta, GA
SECTION I - VETERAN
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*Name of VA medical center or clinic where you receive or plan to receive health care services: |
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Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims.
I certify that I give consent to the individual(s) named in this application to perform personal care services for me (or if the Veteran's Representative, the Veteran) upon being approved as a Primary and/or Secondary Family Caregiver(s) in the Program of Comprehensive Assistance for Family Caregivers. I certify that the information provided in this form is correct and true to the best of my knowledge and belief.
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Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims.
VA FORM |
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SECTION II - PRIMARY FAMILY CAREGIVER APPLICANT (Continued)
I certify that I am at least 18 years of age.
I certify that either: (1) I am a member of the Veteran's family (including a parent, spouse, a son or daughter, a
I agree to perform personal care services as the Primary Family Caregiver for the Veteran named on this application.
I understand that the Veteran or the Veteran's surrogate may request my discharge from the Program of Comprehensive Assistance for Family Caregivers (PCAFC) at any time and that my designation as a Primary Family Caregiver may be revoked or I may be discharged from PCAFC by the Secretary of Veterans Affairs (or designee) as set forth in 38 CFR 71.45.
I understand that participation in the PCAFC does not create an employment relationship between me and the Department of Veterans Affairs.
I certify that the information provided in this form is correct and true to the best of my knowledge and belief.
*Primary Family Caregiver Applicant Signature
*Date (MM/DD/YYYY)
SECTION III - SECONDARY FAMILY CAREGIVER APPLICANT
(Complete if appointing a Secondary Family Caregiver Applicant)
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*First Name
Middle Name
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Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims.
I certify that I am at least 18 years of age.
I certify that either: (1) I am a member of the Veteran's family (including a parent, spouse, a son or daughter, a
I agree to perform personal care services as the Secondary Family Caregiver for the Veteran named on this application.
I understand that the Veteran or the Veteran's surrogate may request my discharge from the Program of Comprehensive Assistance for Family Caregivers (PCAFC) at any time and that my designation as a Secondary Family Caregiver may be revoked or I may be discharged from PCAFC by the Secretary of Veterans Affairs (or designee) as set forth in 38 CFR 71.45.
I understand that participation in the PCAFC does not create an employment relationship between me and the Department of Veterans Affairs.
I certify that the information provided in this form is correct and true to the best of my knowledge and belief.
*Secondary Family Caregiver Applicant Signature
*Date (MM/DD/YYYY)
VA FORM |
Page 4 of 5 |
SECTION III - SECONDARY FAMILY CAREGIVER APPLICANT (Continued) (Complete if appointing more than one Secondary Family Caregiver Applicant)
*Last Name
*First Name
Middle Name
Social Security Number/Tax Identification Number |
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*Current Street Address |
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*City
*State
*Zip Code
*Primary Telephone Number (Including Area Code) |
Alternate Telephone Number (Including Area Code) |
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Email Address |
*Relationship to Veteran (e.g., Spouse, Parent, Son, Daughter, Grandchild, |
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Other) |
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Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims.
I certify that I am at least 18 years of age.
I certify that either: (1) I am a member of the Veteran's family (including a parent, spouse, a son or daughter, a
I agree to perform personal care services as the Secondary Family Caregiver for the Veteran named on this application.
I understand that the Veteran or the Veteran's surrogate may request my discharge from the Program of Comprehensive Assistance for Family Caregivers (PCAFC) at any time and that my designation as a Secondary Family Caregiver may be revoked or I may be discharged from PCAFC by the Secretary of Veterans Affairs (or designee) as set forth in 38 CFR 71.45.
I understand that participation in the PCAFC does not create an employment relationship between me and the Department of Veterans Affairs.
I certify that the information provided in this form is correct and true to the best of my knowledge and belief.
*Secondary Family Caregiver Applicant Signature
*Date (MM/DD/YYYY)
VA FORM |
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