VA Form 10-10EC at a glance
What it is: APPLICATION FOR EXTENDED CARE SERVICES, VA FORM 10-10EC, MAY 2025 Page 2
Who signs: In Section XI, you or an individual to whom you have delegated your Power of Attorney must sign and date.
What to bring and attach to VA Form 10-10EC
What will I need to know in order to complete the form? Current income of Veteran and spouse (stated in frequency of receipt, e.g., per week, bi-weekly, twice monthly, monthly, annually). Current deductible expenses (report monthly or annual expenses unless otherwise stated on the application). Value of fixed and liquid assets of both Veteran and spouse. See Sections V and VI of these instructions for details. All health insurance information covering you even if it is through your spouse (a copy of your insurance card). Medicare information (Part A & Part B) (a copy of your Medicare card). Spousal/Dependent information (including social security number, date of marriage, and date of birth).
Attach copies of Medicare and other health insurance cards, and your Power of Attorney documents to this application.
A filled-in VA Form 10-10EC example: a single Veteran applies for extended care
How to fill out VA Form 10-10EC, box by box
Name and social security number
Section I - General Information. Include your name and full social security number.
Do you have current insurance?
3. Do you have current insurance? YES (If yes, provide a copy of all insurance card(s) covering the Veteran) NO
Current insurance may help to reduce your copayment responsibility.
Current marital status, spouse and dependents
Select only one current marital status (Single Includes Widowed, Divorced, Legally Separated, or Never Married).
Single - With Dependent (Not Institutionalized), Single - With no dependents residing in the community, Married - Living Separate from Spouse (Not Institutionalized), Married - Living Separate from Spouse (Institutionalized), Married - Living with Spouse (Not Institutionalized); Divorced, Legally Separated, or Widowed This Year.
For the purpose of this application a Veteran is considered “Single” when widowed, divorced, legally separated, or never married. Legally separated and divorced are recognized when an official court decree/order exists and must be provided upon request. Do not include spousal information if you and your spouse are legally separated or divorced. Guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.
Section III - Spouse/Dependent Information. Required to determine a Veteran's copay responsibility for extended care services. A dependent is a spouse, biological child, adopted child, or stepchild. A spouse/dependent is considered to be “Non-institutionalized” when residing in the community with or separate from the Veteran. A spouse/dependent is considered to be “Institutionalized” when residing in a nursing home or hospital setting.
Enter 5. SPOUSE'S NAME (Last, First, MI), 5A. SOCIAL SECURITY NUMBER (999-99-9999), 5B. DATE OF BIRTH (MM/DD/YYYY), 5C. DATE OF MARRIAGE (MM/DD/YYYY), 5D. DATE OF LEGAL SEPARATION OR DIVORCE (MM/DD/YYYY) and 5E. DATE OF DEATH (MM/DD/YYYY).
Enter each dependent's name (Last, First, MI), social security number (999-99-9999) and date of birth (MM/DD/YYYY), in 6, 7, 8 and 9.
Financial disclosure
If you do not wish to provide this information you must sign agreeing to make copayments and will be charged the maximum copayment amount for all services.
Section IV - Financial Disclosure. Select only one checkbox.
NO, I am not providing financial details. I understand I will be assessed the maximum copayment amount for extended care services and agree to pay the applicable VA copayment as required by law.
YES, I am providing financial details for the current calendar year.
Fixed assets
Fixed Assets are N/A for Non-Institutional care; Only applies to Institutional (Inpatient) Extended Care Services after 181+ days. Exclude Spouse's Assets when Legally Separated.
1. Primary Residence of Veteran and spouse (Market value minus mortgages or liens).
2. Other Residences/Land/Farm or Ranch (Market value minus mortgages or liens) (Include a second home, vacation home, and/or rental properties).
3. Vehicle(s) (Value minus any outstanding lien).
Liquid assets: cash, other liquid assets and household effects
1. Cash, Amount in Bank Accounts (checking and savings accounts, certificates of deposit, individual retirement accounts, stocks, and bonds).
2. Other Liquid Assets (art, rare coins, stamp collections, collectibles minus the amount you owe on these items).
3. Household Effects (clothing, jewelry, and personal items) (Exclude when a spouse or dependent is residing in community (not institutionalized).
Current gross income
1. Gross income from employment (wages, bonuses, tips, severance pay, and accrued benefits). Select only one.
How Often? - Veteran: Annually, Monthly, Twice Monthly, Bi-Weekly, Weekly.
How Often? - Spouse: Weekly, Bi-Weekly, Twice Monthly, Monthly, Annually.
2. Net income from your farm, ranch, property, or business. Report income from a business (minus business expenses).
3. Other income (social security, retirement, pension, interest, dividends). Report cash gifts, inheritance amounts, interest income, and the standard dividend income from non-tax deferred annuities. Report retirement income and pension income. Report unemployment payments, worker's compensation payments, black lung payments, tort settlement payments, social security payments, and court mandated payments. Report payments from VA or any other Federal programs, and any other income.
Exclude Spouse Income when Legally Separated.
Deductible expenses
Deductible expenses: Monthly average over past 12 months unless otherwise stated. Exclude Spouse Expenses when Legally Separated. Expenses for Veteran, Spouse, and Dependents (average monthly unless otherwise stated on the application).
3. Rent/Mortgage for primary residence only. How Often? Select only one, Annually or Monthly.
Enter 1. Educational expenses for Veteran, spouse or dependent (tuition, books, fees, material, etc.)
Enter 2. Funeral and Burial expenses for spouse or child (including pre-paid arrangements)
4. Utilities for primary residence Report utilities (electricity, gas, water, phone, or internet) in the past year.
Enter 5. Car Payment for one vehicle
Enter 6. Food for Veteran, spouse, and dependents
7. Non-reimbursed medical expenses (copayments for physicians, dentists, medications, Medicare, health insurance, hospital, and nursing home expenses). Report non-reimbursed medical and dental care, medications, eyeglasses, Medicare, medical insurance premiums, medical copayments and other hospital or nursing home expense.
Enter 8. Court-ordered payments (alimony, child support)
9. Insurance (automobile and homeowners, exclude life insurance) Report insurance premiums such as automobile and homeowners. Exclude life insurance premiums.
10. Taxes paid (for personal property, home, automobile, and income) Report taxes paid on property and income over the past 12 months.
Signature, date and certification
Completion of this form with signature of the Veteran or Veteran's representative is certification that the Veteran/representative has received a copy of the Privacy Act Statement and agrees to make appropriate copayments.
Enter SIGNATURE (Sign in ink) and DATE (MM/DD/YYYY).
Enter VETERAN'S NAME (Last, First, MI) and SOCIAL SECURITY NUMBER (999-99-9999).
Read Section XI, Consent for Assignment of Benefits, Section IX, Consent to Agreement to Make Copayments, and Section X, Privacy Act and Paperwork Reduction Act Information.
More rules for VA Form 10-10EC
Based on your marital/dependents status, some income, expenses, and assets might not be used in the calculation of your available resources.
After VA Form 10-10EC information is entered into the system, your local VA medical facility will inform you, or an individual to whom you have delegated your Power of Attorney, on your estimated monthly copayment responsibility for extended care services.
Who must complete the form
You are applying for extended care services
Enrollment is required to determine copay responsibility. You must complete this form if you are applying for extended care services. If you are currently receiving extended care services and you have a change in marital/dependent status or financials you must submit a new 10-10EC application to your local VA medical facility within 10 calendar days of the change. Source: Code of Federal Regulations 17.111 Copayments for Extended Care Services.
What is VA Form 10-10EC used for? To estimate monthly copayment responsibility for extended care services provided to you by VA, either directly, or paid for by the VA. There is no copayment for the first 21 days of extended care services that VA provides to you in any 12-month period.
Common questions about VA Form 10-10EC
Who signs it?
In Section XI, you or an individual to whom you have delegated your Power of Attorney must sign and date.
Where do I file it?
Return the original form and supporting documentation to your local VA medical facility.
Is there a penalty?
Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious, or fraudulent statement or representation. Any materially false, fictitious, or fraudulent statement or representation, made knowingly, is punishable by a fine and/or imprisonment pursuant to title 18, United States Code, Sections 287 and 1001.
Sources
[1] VA Form 10-10EC (MAY 2025), Application for Extended Care Services, Department of Veterans Affairs (the Official source link on this page).
