[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283911-105":53,"doc-detail-283911-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","application-for-champva-benefits-va-form-10-10d","APPLICATION FOR CHAMPVA BENEFITS - VA Form 10-10d","","Application for CHAMPVA benefits collects sponsor (veteran) and applicant information, including names, addresses, Social Security numbers, dates of birth, phone, email, and family relationship details. 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 \u003Cbr>YES     NO   |  | IF \"YES,\"CONTINUE.  \u003Cbr>IF\"NO,\"GO TO SECTIONII   |  |  | DATE OF DEATH (MMDD/YYYY)   |  |  | DID THE VETERAN DIE WHILE ONACTIVE MILITARYSERVCE?  \u003Cbr>□YES □NO   |  |  |  |  |  |\n| SECTIONⅡ-APPLICANT INFORMATION   |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| LAST NAME   |  |  |  | FIRST NAME   |  |  |  |  | MI   | SOCIAL SECURITY  \u003Cbr>NUMBER  \u003Cbr>(999-99-9999)   |  |  | DATE OF BIRTH  \u003Cbr>(MM/DD/YYYY)   |\n| STREET ADDRESS   |  |  |  | CITY   |  |  |  |  | STATE   | ZIP CODE(99999-9999)   |  |  |  |\n| EMAILADDRESS   |  |  |  |  |  | PHONE NUMBER(Include Area Code)  \u003Cbr>((999)999-9999)   |  |  |  |  |  | SEX  \u003Cbr>□FEMALE  \u003Cbr>□MALE   |  |\n| ENROLLED IN MEDICARE  \u003Cbr>□  \u003Cbr>If checkedcomplete VA Form 10-7959c and  \u003Cbr>attach a copy of Medicare Card   |  |  |  | HAS OTHER HEALTH INSURANCE  \u003Cbr>If checked,complete VA Form 10-7959c and  \u003Cbr>attach a copy of insurance card   |  |  |  |  | RELATIONSHIP TOVETERAN (i.e.,spouse,child)   |  |  |  |  |\n| LAST NAME   |  |  |  | FIRST NAME   |  |  |  |  | MI   | SOCIAL SECURITY  \u003Cbr>NUMBER  \u003Cbr>(999-99-9999)   |  |  | DATE OF BIRTH  \u003Cbr>(MM/DD/YYYY)   |\n| STREET ADDRESS   |  |  |  | CITY   |  |  |  |  | STATE   | ZIP CODE (99999-9999)   |  |  |  |\n| EMAILADDRESS   |  |  |  |  |  | PHONE NUMBER(Include Area Code)  \u003Cbr>(999)999-9999   |  |  |  |  |  | SEX  \u003Cbr>□FEMALE  \u003Cbr>□MALE   |  |\n| ENROLLED IN MEDICARE  \u003Cbr>□  \u003Cbr>If checked,complete VA Form 10-7959c and  \u003Cbr>attach a copy of Medicare Card   |  |  |  | HAS OTHER HEALTH INSURANCE  \u003Cbr>If checked,complete VA Form 10-7959c and  \u003Cbr>attach a copy of insurance card   |  |  |  |  | RELATIONSHIP TOVETERAN (i.e.,spouse,child)   |  |  |  |  |\n| LAST NAME   |  |  |  | FIRST NAME   |  |  |  |  | MI   | SOCIALSECURITY  \u003Cbr>NUMBER  \u003Cbr>(999-99-9999)   |  |  | DATE OF BIRTH  \u003Cbr>(MM/DD/YYYY)   |\n| STREET ADDRESS   |  |  |  | CITY   |  |  |  |  | STATE   | ZIP CODE (99999-9999)   |  |  |  |\n| EMAILADDRESS   |  |  |  |  |  | PHONE NUMBER(Include Area Code)  \u003Cbr>(999)999-9999   |  |  |  |  |  | SEX  \u003Cbr>□MALE  \u003Cbr>□FEMALE   |  |\n| ENROLLED IN MEDICARE  \u003Cbr>If checked,complete VA Form 10-7959c and  \u003Cbr>attach a copy of Medicare Card   |  |  |  | HAS OTHER HEALTH INSURANCE  \u003Cbr>If checked,complete VA Form 10-7959c and  \u003Cbr>attach a copy of insurance card   |  |  |  |  | RELATIONSHIP TOVETERAN (i.e.,spouse,child)   |  |  |  |  |\n| SECTIONⅢ-CERTIFICATION   |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| I declare","cbCaipYU9w0cvMvF","https://ap.wps.com/l/cbCaipYU9w0cvMvF","pdf",921652,"English","# SECTION I - SPONSOR INFORMATION\n# SECTION II - APPLICANT INFORMATION\n# SECTION III - CERTIFICATION\n# NOTICE & PRIVACY ACT INFORMATION","[{\"question\":\"What information does Section I collect for the sponsor (veteran)?\",\"answer\":\"Section I gathers the veteran’s last and first name, Social Security number, street address, city, state, ZIP code, country code, phone and email, date of birth, and marriage date, plus whether the veteran is deceased and related death details when applicable.\"},{\"question\":\"What does Section II require from each applicant?\",\"answer\":\"Section II collects the applicant’s personal details (name, Social Security number, date of birth, address, email, phone, and sex) and asks whether the applicant is enrolled in Medicare and whether they have other health insurance, including relationship to the veteran.\"},{\"question\":\"What is required in the certification section?\",\"answer\":\"Section III includes a certification statement under penalty of perjury, the signature and signature date, and an email address. If someone other than the applicant signs, that person’s name, relationship to the applicant(s), address, and phone number must also be provided.\"}]","APPLICATION FOR CHAMPVA BENEFITS - VA Form 10-10d | PDF",1789622384]