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| # | Location | File | Last Modified |
|---|---|---|---|
| 1 | v1_iter_1_VIP_Build_4_Dec_2018_CG.zip\v1_iter_1_VIP_Build_4\portlets\caret-portlet\docroot\jsp\online | vetGeneralInfo.jsp | Wed Jan 16 16:06:54 2019 UTC |
| 2 | v1_iter_1_VIP_Build_4_Dec_2018_CG.zip\v1_iter_1_VIP_Build_4\portlets\caret-portlet\docroot\jsp\online | vetGeneralInfo.jsp | Wed Jan 16 21:50:01 2019 UTC |
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| 147 | wi dth: 60px; | |
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| 161 | ||
| 162 | <script ty pe="text/j avascript" > | |
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| 196 | <p ortlet:par am name="e ntry" valu e="VET_DAS HBOARD"/> | |
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| 198 | ||
| 199 | <portlet:a ctionURL v ar="loadOn lineWelcom eCaregiver "> | |
| 200 | <p ortlet:par am name="j avax.portl et.action" value="do Action" /> | |
| 201 | <p ortlet:par am name="a ction" val ue="loadEn try"/> | |
| 202 | <p ortlet:par am name="e ntry" valu e="CGV_DAS HBOARD"/> | |
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| 205 | <hr style= "margin-to p: 4px; pa dding-top: 10px; mar gin-bottom : 1px; pad ding-botto m: 1px"> | |
| 206 | <%@include file="/js p/online/a pplication /util/prin tInclude.j sp" %> | |
| 207 | ||
| 208 | <div> | |
| 209 | <d iv class=" definition s-seventie s-logo-img "> | |
| 210 | <i mg src="<% =request.g etContextP ath()%>/im ages/va4.j pg" /> | |
| 211 | </ div> | |
| 212 | <s pan class= "definitio ns-seventi es-logo-te xt">Depart ment of Ve teran Affa irs</span> | |
| 213 | <d iv style=" float: rig ht;"> | |
| 214 | ||
| 215 | <div cla ss="home-b utton-cont ent"> | |
| 216 | <c:cho ose> | |
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| 218 | <a class=" icon-home home-butto n" href="$ {loadOnlin eWelcomeVe teran}" >< /a> | |
| 219 | </c:when > | |
| 220 | <c:other wise> | |
| 221 | <a class=" icon-home home-butto n" href="$ {loadOnlin eWelcomeCa regiver}" ></a> | |
| 222 | </c:othe rwise> | |
| 223 | </c:ch oose> | |
| 224 | <div c lass="home -button-ce ntered-tex t">Home</d iv> | |
| 225 | </di v> | |
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| 227 | ||
| 228 | <b r style="c lear: both ;"> | |
| 229 | <s pan style= "font-fami ly: Arial, Helvetica , sans-ser if; font-s ize: 14px; ">Instruct ions for C ompleting Applicatio n for the Program of Comprehen sive Assis tance for Family Car egivers</s pan> | |
| 230 | <d iv style=" clear: bot h; line-he ight: 50%; "> </ div> | |
| 231 | <! -- <br sty le="clear: both;"> - -> | |
| 232 | <s pan style= "font-fami ly: Arial, Helvetica , sans-ser if; font-s ize: 18px; font-weig ht: 600;"> Please Rea d Before Y ou Start.. .</span> | |
| 233 | <d iv style=" clear: bot h; line-he ight: 50%; "> </ div> | |
| 234 | <s pan style= "margin-le ft: 10px; font-style : italic; font-famil y: Arial, Helvetica, sans-seri f; font-si ze: 14px;" >Click on the topics for more informatio n</span> | |
| 235 | <b r style="c lear: both ; line-hei ght: 100%; "> | |
| 236 | ||
| 237 | <d iv class=" dash-butto ns-block"> | |
| 238 | ||
| 239 | ||
| 240 | <d iv class=" dash-butto n-outer" t abindex="0 "> | |
| 241 | <spa n> | |
| 242 | <span class='csp -info-div' >What is V A Form 10- 10CG used for?</span > | |
| 243 | <butto n class="c sp-info-bu tton-plus" onClick=" clickActio n('10-10CG ');"> | |
| 244 | <span id=" 10-10CG" c lass="" st yle="font- family: Ar ial,Helvet ica,sans-s erif; ">+< /span> | |
| 245 | </butt on> | |
| 246 | </sp an> | |
| 247 | </ div> | |
| 248 | <d iv id="x10 -10CG" cla ss="online -prose" st yle="displ ay: none;" tabindex= "0"> | |
| 249 | To a pply for V A's Progra m of Compr ehensive A ssistance for Family Caregiver s. VA will use the i nformation on this f orm to ass ist in det ermining y our eligib ility; a c linical as sessment w ill also b e required . An eligi ble Vetera n may appo int one (1 ) Primary Family Car egiver and up to two (2) Secon dary Famil y Caregive rs. On ave rage, it w ill take 1 5 minutes to complet e the appl ication in cluding th e time it will take you to rea d instruct ions, gath er the nec essary fac ts and fil l out the form. Each time a ne w Caregive r is appoi nted a new Form 10-1 0CG is req uired. | |
| 250 | </ div> | |
| 251 | ||
| 252 | <d iv class=" dash-butto n-outer" t abindex="0 "> | |
| 253 | <spa n> | |
| 254 | <span class='csp -info-div' >Where can I get hel p filling out the fo rm and ans wers to qu estions?</ span> | |
| 255 | <butto n class="c sp-info-bu tton-plus" onClick=" clickActio n('help'); "> | |
| 256 | <span id=" help" clas s="" style ="font-fam ily: Arial ,Helvetica ,sans-seri f; ">+</sp an> | |
| 257 | </butt on> | |
| 258 | </sp an> | |
| 259 | </ div> | |
| 260 | <d iv id="xhe lp" class= "online-pr ose" style ="display: none;" ta bindex="0" > | |
| 261 | You may us e ANY of t he followi ng to requ est assist ance: Ask VA to help you fill out the fo rm by call ing us at 1-877-222- VETS (8387 ). Access VA's websi te at <a t arget="_bl ank" href= "http:// DNS . URL ">http:// DNS . URL </a> and s elect "Con tact the V A". Locate and conta ct the Car egiver Sup port Coord inator at your neare st VA heal th care fa DN S
|
|
| 262 | </ div> | |
| 263 | ||
| 264 | <d iv class=" dash-butto n-outer" t abindex="0 "> | |
| 265 | <spa n> | |
| 266 | <span class='csp -info-div' >Definitio ns of term s used in this form< /span> | |
| 267 | <butto n class="c sp-info-bu tton-plus" onClick=" clickActio n('definit ions');"> | |
| 268 | <span id=" definition s" class=" " style="f ont-family : Arial,He lvetica,sa ns-serif; ">+</span> | |
| 269 | </butt on> | |
| 270 | </sp an> | |
| 271 | </ div> | |
| 272 | <d iv id="xde finitions" class="on line-prose -definitio ns" style= "display: none;" tab index="0"> | |
| 273 | <div class="on line-defin itions-tit le">Caregi ver Suppor t Coordina tor (CSC): </div> | |
| 274 | <div c lass="font -weight-no rmal"> | |
| 275 | A VA cli nical prof essional w ho connect s Caregive rs of Vete rans with VA and com munity res ources off ering supp ortive pro grams and services. Caregiver Support Co ordinators are locat ed at ever y VA medic al center and are de signated s pecialists in Caregi ving issue s. | |
| 276 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 277 | </div> | |
| 278 | ||
| 279 | <div c lass="onli ne-definit ions-title ">Family M ember:</di v> | |
| 280 | <div c lass="font -weight-no rmal"> | |
| 281 | A member of the Ve teran's or Service m ember's fa mily (incl uding a pa rent, a sp ouse, a so n or daugh ter, a ste p-family m ember, and an extend ed family member), o r an indiv idual who lives full -time with the Veter an or Serv ice member , or will do so if a pproved as a Primary or Second ary Family Caregiver . | |
| 282 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 283 | </div> | |
| 284 | ||
| 285 | <div c lass="onli ne-definit ions-title ">Injured in the Lin e of Duty (LOD):</di v> | |
| 286 | <div c lass="font -weight-no rmal"> | |
| 287 | An injur y incurred or aggrav ated durin g active m ilitary se rvice, unl ess the in jury resul ted from t he Veteran 's or Serv ice member 's willful misconduc t or abuse of alcoho l or drugs , or it oc curred whi le that in dividual w as avoidin g duty by desertion, or absent without l eave which materiall y interfer ed with th e performa nce of mil itary duty . | |
| 288 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 289 | </div> | |
| 290 | ||
| 291 | <div c lass="onli ne-definit ions-title ">Power of Attorney (POA):</di v> | |
| 292 | <div c lass="font -weight-no rmal"> | |
| 293 | A Power of Attorne y is an au thorizatio n for some one to act on the Ve teran's or Service m ember's be half when completing this form . | |
| 294 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 295 | </div> | |
| 296 | ||
| 297 | <div c lass="onli ne-definit ions-title ">Primary Family Car egiver:</d iv> | |
| 298 | <div c lass="font -weight-no rmal"> | |
| 299 | A Family Member (d efined her ein), who is designa ted as a " primary pr ovider of personal c are servic es" under 38 U.S.C. §1720G(a)( 7)(A); and who meets the requi rements of 38 C.F.R. §71.25. | |
| 300 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 301 | </div> | |
| 302 | ||
| 303 | <div c lass="onli ne-definit ions-title ">Represen tative:</d iv> | |
| 304 | <div c lass="font -weight-no rmal"> | |
| 305 | Refers t o a Vetera n's or Ser vice membe r's court- appointed legal guar dian or sp ecial guar dian, Dura ble POA fo r Health C are, or ot her design ated healt h care age nt. Copies of docume ntation re garding re presentati ves are re quested on this appl ication. | |
| 306 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 307 | </div> | |
| 308 | ||
| 309 | <div c lass="onli ne-definit ions-title ">Secondar y Family C aregiver:< /div> | |
| 310 | <div c lass="font -weight-no rmal"> | |
| 311 | An indiv idual appr oved as a "provider of persona l care ser vices" for the eligi ble Vetera n under 38 U.S.C. §1 720G(a)(7) (A); meets the requi rements of 38 C.F.R. §71.25; a nd general ly serves as a back- up to the Primary Fa mily Careg iver. | |
| 312 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 313 | </div> | |
| 314 | ||
| 315 | <div c lass="onli ne-definit ions-title ">Stipend: </div> | |
| 316 | <div c lass="font -weight-no rmal"> | |
| 317 | An allow ance given to a Prim ary Family Caregiver in acknow ledgement of the sac rifices th ey are mak ing to car e for a se riously in jured elig ible Veter an (as def ined in 38 C.F.R §71 .15). | |
| 318 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 319 | </div> | |
| 320 | </ div> | |
| 321 | ||
| 322 | ||
| 323 | <d iv class=" dash-butto n-outer" t abindex="0 "> | |
| 324 | <spa n> | |
| 325 | <span class='csp -info-div' >Who shoul d apply fo r VA's Pro gram of Co mprehensiv e Assistan ce for Fam ily Caregi vers?</spa n> | |
| 326 | <butto n class="c sp-info-bu tton-plus" onClick=" clickActio n('whoShou ldApply'); "> | |
| 327 | <span id ="whoShoul dApply" cl ass="" sty le="font-f amily: Ari al,Helveti ca,sans-se rif; ">+</ span> | |
| 328 | </butt on> | |
| 329 | </sp an> | |
| 330 | </ div> | |
| 331 | <d iv id="xwh oShouldApp ly" style= "display: none;" tab index="0"> | |
| 332 | <tab le class=" fixed"> | |
| 333 | <col s tyle="widt h: 207px;" /> | |
| 334 | <col s tyle="widt h: 315px;" /> | |
| 335 | <col s tyle="widt h: 189px;" /> | |
| 336 | <col s tyle="widt h: 189px;" /> | |
| 337 | <tr> | |
| 338 | <td>IF T HE INDIVID UAL IS A:< /td> | |
| 339 | <td>AND< /td> | |
| 340 | <td>AND< /td> | |
| 341 | <td>THEN </td> | |
| 342 | </tr> | |
| 343 | <tr> | |
| 344 | <td><spa n class="t dbold">Vet eran</span > or <span class="td bold">Serv ice member </span> wh o has been issued a date of me dical disc harge from the milit ary</td> | |
| 345 | <td>Requ ires on-go ing superv ision or a ssistance with perfo rming basi c function s of every day life d ue to a se rious inju ry or ment al disorde r (includi ng traumat ic brain i njury, psy chological trauma or other men tal disord er) incurr ed or aggr avated <sp an class=" tdbold">in the line of duty on or after September 11, 2001</ span></td> | |
| 346 | <td>Requ ires at le ast 6 mont hs of cont inuous Car egiver Sup port</td> | |
| 347 | <td>The Veteran or Service m ember may meet the c riteria fo r VA's Pro gram of Co mprehensiv e Assistan ce for Fam ily Caregi vers. Com plete this form to a pply</td> | |
| 348 | </tr> | |
| 349 | </ta ble> | |
| 350 | <div class="on line-prose " style="m argin-top: 7px; marg in-bottom: 7px; marg in-left: 1 2px"> | |
| 351 | Veterans a nd Service members w ho do not meet the c riteria fo r VA's Pro gram of Co mprehensiv e Assistan ce for Fam ily Caregi vers may b e eligible for VA he alth benef its and ot her caregi ver suppor t services . To find out about other care giver supp ort servic es, contac t the Care giver Supp ort Coordi nator (CSC ) at your local VA h ealth care facility. To obtain the name of your lo cal CSC, c ontact the <span cla ss="tdbold ">Caregive r Support Line</span > at 1-855 -260-3274 <span clas s="tdbold" >or go to <a target= "_blank" h ref="http: // DNS . URL /">http:// DNS . URL /</a> and use the Fi nd Your Lo cal Caregi ver Suppor t Coordina tor option .</span>. | |
| 352 | </di v> | |
| 353 | </ div> | |
| 354 | ||
| 355 | ||
| 356 | <d iv class=" dash-butto n-outer" t abindex="0 "> | |
| 357 | <spa n> | |
| 358 | <span class='csp -info-div' >Getting S tarted</sp an> | |
| 359 | <butto n class="c sp-info-bu tton-plus" onClick=" clickActio n('getting Started'); "> | |
| 360 | <span id=" gettingSta rted" clas s="" style ="font-fam ily: Arial ,Helvetica ,sans-seri f; ">+</sp an> | |
| 361 | </butt on> | |
| 362 | </sp an> | |
| 363 | </ div> | |
| 364 | <d iv id="xge ttingStart ed" class= "online-pr ose-defini tions" sty le="displa y: none;" tabindex=" 0"> | |
| 365 | <div c lass="font -weight-no rmal"> | |
| 366 | Answer a ll questio ns on the form. If y ou are not enrolled in VA's he alth care system or are curren tly Active Duty unde rgoing med ical disch arge, subm it VA Form 10-10EZ " Applicatio n for Heal th Benefit s" with th is form. E nrolled Ve terans may submit VA Form 10-1 0EZR "Heal th Benefit s Renewal Form" with their com pleted VA Form 10-10 CG to prov ide inform ation upda tes. Do NO T exceed t he designa ted spaces (e.g., do NOT exten d Last Nam e into Fir st Name ar ea). The V eteran's o r Service member's r epresentat ive or POA may compl ete this a pplication ; however the POA/Re presentati on documen ts must be provided with this applicatio n. | |
| 367 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 368 | </div> | |
| 369 | ||
| 370 | <div c lass="onli ne-definit ions-title ">SECTION I --VETERA N AND SERV ICE MEMBER GENERAL I NFORMATION </div> | |
| 371 | <div c lass="font -weight-no rmal"> | |
| 372 | Directio ns for Sec tion I --V eteran/Ser vice membe r, represe ntative or POA, plea se answer all questi ons, sign and date. | |
| 373 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 374 | </div> | |
| 375 | ||
| 376 | <div c lass="onli ne-definit ions-title ">SECTION II --PRIMA RY FAMILY CAREGIVER GENERAL IN FORMATION< /div> | |
| 377 | <div c lass="font -weight-no rmal"> | |
| 378 | Directio ns for Sec tion II -- Primary Fa mily Careg iver appli cant, plea se answer all questi ons, inclu ding healt h insuranc e informat ion, sign and date. | |
| 379 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 380 | </div> | |
| 381 | ||
| 382 | <div c lass="onli ne-definit ions-title ">SECTION III --SECO NDARY FAMI LY CAREGIV ER(S) GENE RAL INFORM ATION</div > | |
| 383 | <div c lass="font -weight-no rmal"> | |
| 384 | Direct ions for S ection III --Seconda ry Family Caregiver applicant( s) please answer all questions , sign and date. A V eteran/Ser vice membe r may appo int up to two Second ary Family Caregiver s but this is not re quired. If a Veteran /Serviceme nber elect s to appoi nt a Secon dary Famil y Caregive r at a lat er time, S ections I and III in a new 10- 10CG must be complet ed. | |
| 385 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 386 | </div> | |
| 387 | </ div> | |
| 388 | ||
| 389 | <d iv class=" dash-butto n-outer" t abindex="0 "> | |
| 390 | <spa n> | |
| 391 | <span class='csp -info-div' >Submittin g your App lication</ span> | |
| 392 | <butto n class="c sp-info-bu tton-plus" onClick=" clickActio n('submitt ing');"> | |
| 393 | <span id=" submitting " class="" style="fo nt-family: Arial,Hel vetica,san s-serif; " >+</span> | |
| 394 | </butt on> | |
| 395 | </sp an> | |
| 396 | </ div> | |
| 397 | <d iv id="xsu bmitting" class="onl ine-prose- definition s" style=" display: n one;" tabi ndex="0"> | |
| 398 | <div c lass="font -weight-no rmal"> | |
| 399 | 1. Read Paperwork Reduction and Privac y Act Info rmation. | |
| 400 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 401 | </div> | |
| 402 | ||
| 403 | <div c lass="font -weight-no rmal"> | |
| 404 | 2. The V eteran or an individ ual delega ted as the Veteran's represent ative/POA must sign and date t he form. | |
| 405 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 406 | </div> | |
| 407 | ||
| 408 | <div c lass="font -weight-no rmal"> | |
| 409 | 3. Attac h POA/Repr esentation documents to the ap plication, if applic able. | |
| 410 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 411 | </div> | |
| 412 | <div c lass="font -weight-no rmal"> | |
| 413 | 4. For e xpedited p rocessing, mail this applicati on to: | |
| 414 | <span cl ass="onlin e-prose-de finitions- address-li ne">Progra m of Compr ehensive A ssistance for Family Caregiver s</span> | |
| 415 | <span cl ass="onlin e-prose-de finitions- address-li ne">Health Eligibili ty Center< /span> | |
| 416 | <span cl ass="onlin e-prose-de finitions- address-li ne">2957 C lairmont R oad NE, St e 200</spa n> | |
| 417 | <span cl ass="onlin e-prose-de finitions- address-li ne">Atlant a, GA 3032 9-1647</sp an> | |
| 418 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 419 | </div> | |
| 420 | <div c lass="font -weight-no rmal"> | |
| 421 | If you pre fer to pre sent or ta ke this ap plication in person, you may h and carry the printe d and sign ed applica tion to yo ur local V A Medical Center Car egiver Sup port Coord inator (CS C). To obt ain the na me of your local CSC , contact the <span class="tdb old">Careg iver Suppo rt Line</s pan> at <s pan class= "tdbold">1 -855-260-3 274 or go to <a targ et="_blank " href="ht tp:// DNS . URL ">http:// DNS . URL </a> and u se the Fin d Your Loc al Caregiv er Support Coordinat or option< /span>. | |
| 422 | <div sty le="clear: both; lin e-height: 50%;">&nbs p;</div> | |
| 423 | </div> | |
| 424 | </ div> | |
| 425 | ||
| 426 | ||
| 427 | <d iv class=" dash-butto n-outer" t abindex="0 "> | |
| 428 | <spa n> | |
| 429 | <span class='csp -info-div' >The Paper work Reduc tion ACT</ span> | |
| 430 | <butto n class="c sp-info-bu tton-plus" onClick=" clickActio n('paperwo rk');"> | |
| 431 | <span id=" paperwork" class="" style="fon t-family: Arial,Helv etica,sans -serif; "> +</span> | |
| 432 | </butt on> | |
| 433 | </sp an> | |
| 434 | </ div> | |
| 435 | <d iv id="xpa perwork" c lass="onli ne-prose" style="dis play: none ;" tabinde x="0"> | |
| 436 | This informati on collect ion is in accordance with the clearance requiremen ts of sect ion 3507 o f the Pape rwork Redu ction Act of 1995. P ublic repo rting burd en for thi s collecti on of info rmation is estimated to averag e 15 minut es per res ponse, inc luding the time to r ead instru ctions, ga ther neces sary data, and fill out the fo rm. Respon dents shou ld be awar e that not withstandi ng any oth er provisi on of law, no person shall be subject to any penal ty for fai ling to co mply with a collecti on of info rmation if it does n ot display a current ly valid O MB control number. C ompletion of this fo rm is mand atory for eligible V eterans wh o wish to participat e in the C aregiver P rogram. | |
| 437 | </ div> | |
| 438 | ||
| 439 | ||
| 440 | <d iv class=" dash-butto n-outer" t abindex="0 "> | |
| 441 | <spa n> | |
| 442 | <span class='csp -info-div' >Privacy A CT Informa tion</span > | |
| 443 | <butto n class="c sp-info-bu tton-plus" onClick=" clickActio n('privacy ');"> | |
| 444 | <span id=" privacy" c lass="" st yle="font- family: Ar ial,Helvet ica,sans-s erif; ">+< /span> | |
| 445 | </butt on> | |
| 446 | </sp an> | |
| 447 | </ div> | |
| 448 | <d iv id="xpr ivacy" cla ss="online -prose" st yle="displ ay: none;" tabindex= "0"> | |
| 449 | VA i s asking y ou to prov ide the in formation on this fo rm under 3 8 U.S.C. S ections 10 1, 5303A, 1705, 1710 , 1720B, a nd 1720G, in order f or VA to d etermine y our eligib ility for medical be nefits. In formation you supply may be ve rified thr ough a com puter-matc hing progr am. VA may disclose the inform ation that you put o n the form as permit ted by law . VA may m ake a "rou tine use" disclosure of the in formation as outline d in the P rivacy Act systems o f records, "Patient Medical Re cords --VA " (24VA19) , | |
| 450 | "Enrollmen t and Elig ibility Re cords --VA " (147VA16 ), and "He alth Admin istration Center Civ ilian Heal th and Med ical progr am Records -- VA" (54 VA17) and in accorda nce with t he VHA Not ice of Pri vacy Pract ices. Prov iding the requested informatio n, includi ng Social Security N umber, is voluntary, but if an y or all o f the requ ested info rmation is not provi ded, it ma y delay or result in denial of your requ est for he alth care benefits. Failure to furnish t he informa tion will not have a ny effect on any oth er benefit s to which you may b e entitled . If you p rovide VA your Socia l Security Number, V A will use it to adm inister yo ur VA bene fits. VA m ay also us e this inf ormation t o identify Veterans and person s claiming or receiv ing VA ben efits, and their rec ords, and for other purposes a uthorized or require d by law. | |
| 451 | </ div> | |
| 452 | ||
| 453 | ||
| 454 | ||
| 455 | </ div> | |
| 456 | ||
| 457 | </div> |
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