VA · Official form

VA Form 10-10EC: Application for Extended Care Services

VA Form 10-10EC is the application Veterans use to request VA extended care services, such as nursing home care, adult day health care, or in-home care. VA also uses the financial details on the form to work out any copays.

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What is VA Form 10-10EC?

Extended care, sometimes called long-term care, covers services a Veteran may need over an extended period: community living centers, adult day health care, respite care, home-based care, and similar programs. VA Form 10-10EC starts that process and documents the Veteran's household finances.

Because copays for extended care depend on income and assets, the form asks for detailed information about the Veteran and spouse: income, expenses, assets, and dependents. VA uses this to determine whether the Veteran owes a copay and how much, so accuracy matters.

Who files VA Form 10-10EC?

Veterans applying for VA extended care services such as nursing home or community living center care
Veterans requesting adult day health care, respite care, or home and community based services
Spouses or caregivers helping a Veteran complete the financial disclosure sections
Veterans already receiving extended care who are asked by VA to update their financial information

How to fill out VA Form 10-10EC

Collect documentation of household income, expenses, and assets for you and your spouse before you start.
Complete the personal and demographic sections, then the financial sections covering income, assets, and deductible expenses.
Answer the questions about the type of extended care you are requesting.
Sign and date the form; an unsigned application cannot be processed.
Return the completed form to the social worker or enrollment office at the VA medical center where you receive or are requesting care.

Quick fill VA Form 10-10EC on this page

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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 35 fields

SECTION 1 - GENERAL INFORMATION. 1. VETERAN'S NAME (Last, First, Middle Initial).

2. SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

SECTION 2 - INSURANCE INFORMATION. 3. DO YOU HAVE CURRENT INSURANCE? YES (If yes, provide a copy of all insurance card(s) covering the

SECTION 3 - SPOUSE / DEPENDENT INFORMATION. 4. CURRENT MARITAL STATUS (Select only one) (Single Includes Widowed, Divorced, Legally

5. SPOUSE'S NAME (Last, First, Middle Initial).

5. A. SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

5B. DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

5C. DATE OF MARRIAGE. Enter 2 digit month, 2 digit day and 4 digit year.

5D. DATE OF LEGAL SEPARATION OR DIVORCE. Enter 2 digit month, 2 digit day and 4 digit year.

5E. DATE OF DEATH. Enter 2 digit month, 2 digit day and 4 digit year.

6. DEPENDENT NAME (Last, First, Middle Initial). Line 1 of 4.

6. A. SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

6B. DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

7. DEPENDENT NAME (Last, First, Middle Initial). Line 2 of 4.

7. A. SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

7B. DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

8. DEPENDENT NAME (Last, First, Middle Initial). Line 3 of 4.

8. A. SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

8B. DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

9. DEPENDENT NAME (Last, First, Middle Initial). Line 4 of 4.

9. A. SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

9B. DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

SECTION 4 - FINANCIAL DISCLOSURE. We need to collect information regarding income, assets and expenses for you and your spouse. If you do

SECTION 5 - FIXED ASSETS. (N / A. for Non-Institutional care; Only applies to Institutional (Inpatient) Extended Care Services after 181+

1. SPOUSE. Enter dollar amount.

2. Other Residences / Land / Farm or Ranch (Market value minus mortgages or liens) (Include a second home, vacation home, and / or rental

2. SPOUSE. Enter dollar amount.

3. Vehicle(s) (Value minus any outstanding lien). VETERAN. Enter dollar amount.

3. SPOUSE. Enter dollar amount.

SECTION 6 - LIQUID ASSETS. 1. Cash, Amount in Bank Accounts (checking and savings accounts, certificates of deposit, individual retirement

1. SPOUSE. Enter dollar amount.

2. Other Liquid Assets (art, rare coins, stamp collections, collectibles minus the amount you owe on these items). VETERAN. Enter dollar

2. SPOUSE. Enter dollar amount.

3. Household Effects (clothing, jewelry, and personal items) (Exclude when a spouse or dependent is residing in community (not

3. SPOUSE. Enter dollar amount.

Page 4 26 fields

SECTION 7 - CURRENT GROSS INCOME. (Exclude Spouse Income when Legally Separated). 1. Gross income from employment (wages, bonuses, tips,

1B. How Often? Spouse. Weekly.

1. Gross income from employment (wages, bonuses, tips, severance pay, and accrued benefits). VETERAN. Enter dollar amount.

1. SPOUSE. Enter dollar amount.

2. Net income from your farm / ranch, property, or business. A. How Often? Veteran. Annually.

2B. How Often? Spouse. Weekly.

2. Net income from your farm, ranch, property, or business. VETERAN. Enter dollar amount.

2. SPOUSE. Enter dollar amount.

3. Other income (social security, retirement, pension, interest, dividends). A. How Often? Veteran. Annually.

3B. How Often? Spouse. Monthly.

3. Other income (social security, retirement, pension, interest, dividends). VETERAN. Enter dollar amount.

3. SPOUSE. Enter dollar amount.

SECTION 8 - DEDUCTIBLE EXPENSES (Monthly average over past 12 months unless otherwise stated) (Exclude Spouse Expenses when Legally

2. Funeral and Burial expenses for spouse or child (including pre-paid arrangements). AMOUNT. Enter dollar amount.

3. How Often? Annually.

3. AMOUNT. Enter dollar amount.

4. Utilities for primary residence. AMOUNT. Enter dollar amount.

5. Car Payment for one vehicle. AMOUNT. Enter dollar amount.

6. Food for Veteran, spouse, and dependents. AMOUNT. Enter dollar amount.

7. Non-reimbursed medical expenses (copayments for physicians, dentists, medications, Medicare, health insurance, hospital, and nursing

8. Court-ordered payments (alimony, child support). AMOUNT. Enter dollar amount.

9. Insurance (automobile and homeowners, exclude life insurance). AMOUNT. Enter dollar amount.

10. Taxes paid (for personal property, home, automobile, and income). AMOUNT. Enter dollar amount.

DATE. Enter 2 digit month, 2 digit day and 4 digit year.

VETERAN'S NAME (Last, First, Middle Initial).

SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

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Frequently asked questions

Will I have to pay for VA extended care?

It depends. Some Veterans, including many with service-connected conditions, pay nothing. Others pay a copay based on the financial information reported on the 10-10EC. VA calculates this after reviewing your application.

Do I need to be enrolled in VA health care first?

Generally yes. Extended care services are provided through the VA health care system, so most applicants are already enrolled. If you are not, talk to the enrollment office at your VA medical center about applying with VA Form 10-10EZ as well.

VA Form 10-10EC: Application for Extended Care Services

What is VA Form 10-10EC?

Who files VA Form 10-10EC?

How to fill out VA Form 10-10EC

Quick fill VA Form 10-10EC on this page

Frequently asked questions

Related forms

VA Form 10-10EZ, Application for Health Benefits

VA Form 10-10EZR: Health Benefits Update Form

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