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VA Form 10-10CG: Application for Comprehensive Assistance for Family Caregivers Program

VA Form 10-10CG is the joint application for the Program of Comprehensive Assistance for Family Caregivers (PCAFC), which can provide a monthly stipend, health coverage, training, and respite support to caregivers of eligible seriously injured or ill veterans.

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What is VA Form 10-10CG?

VA Form 10-10CG, Application for Comprehensive Assistance for Family Caregivers Program, is completed jointly by the veteran (or service member) and the person applying to be their family caregiver. The form collects both parties' identifying information, their relationship and living situation, and designates a primary caregiver and up to two secondary caregivers. PCAFC eligibility is based on the veteran having a serious injury or illness in the line of duty and needing in-person personal care services, with the details assessed by VA after the application is submitted.

Approved primary family caregivers may receive a monthly stipend, access to health care through CHAMPVA if not otherwise covered, mental health services, training, and respite care; secondary caregivers receive a subset of benefits. VA notes that a new 10-10CG is required each time a new caregiver is appointed. The application starts a process that includes eligibility review, a caregiver assessment, training, and a home visit before approval.

Who files VA Form 10-10CG?

Family members or others who live with (or will live with) a veteran and want to serve as the primary family caregiver
Veterans or service members with a serious injury or illness incurred or aggravated in the line of duty who need personal care services
People applying to be secondary family caregivers who back up the primary caregiver
Current program participants submitting a new application to appoint a different caregiver

How to fill out VA Form 10-10CG

Review PCAFC eligibility at va.gov with the veteran so both applicants understand the criteria and benefits.
Complete the veteran section and the caregiver sections together, since the application requires information and signatures from the veteran and each caregiver applicant.
Designate the primary caregiver and any secondary caregivers where the form asks.
Have all applicants sign and date the form.
Submit it online through the caregiver application tool at va.gov, mail the completed PDF to the address in the form instructions, or get help from the Caregiver Support Coordinator at your VA medical center; VA then schedules the assessments that complete the process.

Worth knowing: There is also a general Caregiver Support Program with services for caregivers who do not qualify for PCAFC. If the 10-10CG application is denied, ask your VA medical center's Caregiver Support Coordinator about the Program of General Caregiver Support Services.

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These are the form's own fields, in the order they appear on the pages. Fill in what you know; anything left blank stays a fillable field in the PDF, so you can finish it in any PDF reader. Nothing you type here is sent to VA.

Page 3 18 fields

See Attention information above. SECTION 1 - VETERAN. 1. Last Name*. *This is a required field.

2. First Name*. *This is a required field.

3. Middle Name.

4. Suffix.

5. Social Security Number / Tax Identification Number. Enter 9 digit social security number or tax identification number.

6. Date of Birth*. *This is a required field. Enter 2 digit month, 2 digit day and 4 digit year.

7. Birth Sex. Male.

8. Current Street Address (where you reside, not a P O Box)*. *This is a required field.

9. City*. *This is a required field.

10. County*. *This is a required field.

11. State*. *This is a required field.

12. Zip Code*. *This is a required field. Enter 5 digit zip code, with optional hyphen and last 4 digits.

13. Primary Telephone Number (including area code)*. *This is a required field.

14. Alternate Telephone Number (Including area code).

15. Email Address.

16. Name of V. A. medical center or clinic where you receive or plan to receive health care services*. *This is a required field.

See information and certification above. 17. Veteran or Representative Signature*. *This is a required field.

18. Date of Signature*. *This is a required field. Enter 2 digit month, 2 digit day and 4 digit year.

Page 4 23 fields

SECTION 2 - PRIMARY FAMILY CAREGIVER APPLICANT. 1. Last Name*. *This is a required field.

2. First Name*. *This is a required field.

3. Middle Name.

4. Suffix.

5. Social Security Number / Tax Identification Number. Enter 9 digit social security number or tax identification number.

6. Date of Birth*. *This is a required field. Enter 2 digit month, 2 digit day and 4 digit year.

7. Birth Sex. Male.

8. Current Street Address (where you reside, not a P O Box)*. *This is a required field.

9. City*. *This is a required field.

10. County*. *This is a required field.

11. State*. *This is a required field.

12. Zip Code*. *This is a required field. Enter 5 digit zip code, with optional hyphen and last 4 digits.

13. Mailing Address, if different from Street Address.

14. City.

15. County.

16. State.

17. Zip Code. Enter 5 digit zip code, with optional hyphen and last 4 digits.

18. Primary Telephone Number (including area code)*. *This is a required field.

19. Alternate Telephone Number (Including area code).

20. Email Address.

21. Relationship to Veteran (for example Spouse, Parent, Son, Daughter, Grandchild, Other)*. *This is a required field.

See certification above. 22. Primary Family Caregiver Applicant Signature)*. *This is a required field.

23. Date of Signature*. *This is a required field. Enter 2 digit month, 2 digit day and 4 digit year.

Page 5 23 fields

SECTION 3 - SECONDARY FAMILY CAREGIVER APPLICANT (Complete if appointing a Secondary Family Caregiver). 1. Last Name*. *This is a required

2. First Name*. *This is a required field.

3. Middle Name.

4. Suffix.

5. Social Security Number / Tax Identification Number. Enter 9 digit social security number or tax identification number.

6. Date of Birth*. *This is a required field. Enter 2 digit month, 2 digit day and 4 digit year.

7. Birth Sex. Male.

8. Current Street Address (where you reside, not a P O Box)*. *This is a required field.

9. City*. *This is a required field.

10. County*. *This is a required field.

11. State*. *This is a required field.

12. Zip Code*. *This is a required field. Enter 5 digit zip code, with optional hyphen and last 4 digits.

13. Mailing Address, if different from Street Address.

14. City.

15. County.

16. State.

17. Zip Code. Enter 5 digit zip code, with optional hyphen and last 4 digits.

18. Primary Telephone Number (including area code)*. *This is a required field.

19. Alternate Telephone Number (Including area code).

20. Email Address.

21. Relationship to Veteran (for example Spouse, Parent, Son, Daughter, Grandchild, Other)*. *This is a required field.

See certification above. 22. Secondary Family Caregiver Applicant Signature*. *This is a required field.

23. Date of Signature*. *This is a required field. Enter 2 digit month, 2 digit day and 4 digit year.

Page 6 23 fields

SECTION 3 - SECONDARY FAMILY CAREGIVER APPLICANT (Continued) (Complete if appointing a Secondary Family Caregiver). 1. Last Name*. *This is

2. First Name*. *This is a required field.

3. Middle Name.

4. Suffix.

5. Social Security Number / Tax Identification Number. Enter 9 digit social security number or tax identification number.

6. Date of Birth*. *This is a required field. Enter 2 digit month, 2 digit day and 4 digit year.

7. Birth Sex. Male.

8. Current Street Address (where you reside, not a P O Box)*. *This is a required field.

9. City*. *This is a required field.

10. County*. *This is a required field.

11. State*. *This is a required field.

12. Zip Code*. *This is a required field. Enter 5 digit zip code, with optional hyphen and last 4 digits.

13. Mailing Address, if different from Street Address.

14. City.

15. County.

16. State.

17. Zip Code. Enter 5 digit zip code, with optional hyphen and last 4 digits.

18. Primary Telephone Number (including area code)*. *This is a required field.

19. Alternate Telephone Number (Including area code).

20. Email Address.

21. Relationship to Veteran (for example Spouse, Parent, Son, Daughter, Grandchild, Other)*. *This is a required field.

See certification above. 22. Secondary Family Caregiver Applicant Signature*. *This is a required field.

23. Date of Signature*. *This is a required field. Enter 2 digit month, 2 digit day and 4 digit year.

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Frequently asked questions

What benefits do approved caregivers receive?

Approved primary family caregivers may receive a monthly stipend, health care coverage through CHAMPVA if they have no other coverage, caregiver training, mental health support, and respite care so they can take breaks. Secondary caregivers receive training and some support services but not the stipend. Exact benefits depend on the approval and current program rules.

Does submitting the 10-10CG mean we are approved?

No. The application starts a multi-step process: VA reviews eligibility, assesses the veteran's need for personal care services, evaluates and trains the caregiver applicants, and conducts a home visit before making a decision. Your local Caregiver Support Coordinator can explain the timeline and status.

What if we want to change who the caregiver is later?

VA requires a new 10-10CG each time a new caregiver is appointed. Submit a fresh application naming the new person, and contact the Caregiver Support Program at your facility so the change is processed correctly.

VA Form 10-10CG: Application for Comprehensive Assistance for Family Caregivers Program

What is VA Form 10-10CG?

Who files VA Form 10-10CG?

How to fill out VA Form 10-10CG

Quick fill VA Form 10-10CG on this page

Frequently asked questions

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