How to Fill Out and Submit VA Form 10-10EC: Copays and Waivers

VA Form 10-10EC is the financial disclosure the Department of Veterans Affairs uses to set your copayment for extended care services such as nursing home stays, adult day health care, and respite care. You list your household income, assets, and deductible expenses, then hand the completed form and supporting documents to Social Work staff at your local VA medical facility. Staff run the numbers through the formula in 38 CFR 17.111 and tell you what, if anything, you owe per day of care after the first 21 free days in each 12-month period.

Check Whether You Need To File It at All

Several groups of veterans owe no extended care copayment and don’t need to submit a financial disclosure. Under 38 CFR 17.111, you’re exempt if any of the following applies:

You receive VA disability compensation for a service-connected condition rated 10 percent or higher.
Your household income falls below the VA pension threshold.
The extended care treats a service-connected condition, even one rated at zero percent.
You are catastrophically disabled (this exemption covers adult day health care, noninstitutional respite care, and noninstitutional geriatric care).
You fall into one of the specific exposure or condition categories: Vietnam-era herbicide exposure, radiation exposure, Gulf War service, treatment for military sexual trauma, or treatment for certain head or neck cancers.¹

If none of those fit you, the VA needs a completed 10-10EC before it can assign your copayment rate. Skipping it when you’re required to file doesn’t save you money; the VA can default you to the highest copayment tier.²

Which Services the Form Covers

The 10-10EC governs copayments for seven long-term and geriatric services: nursing home care, domiciliary care, adult day health care, institutional and noninstitutional geriatric evaluation, and institutional and noninstitutional respite care. Hospice care is explicitly excluded from the nursing home category and runs on separate rules.¹ Ordinary outpatient and inpatient copays are set by a different process, so don’t use this form for those.

Documents To Gather Before You Start

The biggest slowdown people run into is filling in half the form and then hunting for last year’s tax paperwork. Pull the records first.

Identity and Household

You’ll write in your full name, Social Security number, and (if married) your spouse’s Social Security number. List every dependent — spouse, children, or anyone else who relies on you financially — with names and dates of birth. Household size feeds directly into the copayment calculation, so leaving a dependent off can push your rate up.³

Income

Report your current income and your spouse’s. The form treats income broadly: wages, business income after business expenses, bonuses, tips, severance, interest, standard dividends, retirement distributions, pension payments, Social Security, unemployment, worker’s compensation, tort settlement proceeds, court-ordered payments, and any payments from VA or other federal programs.⁴ Enter each amount at the frequency you receive it — weekly, monthly, or annually. Keep W-2s, 1099s, Social Security benefit statements, and retirement account records within reach so the numbers you write match the paperwork.

Liquid Assets

Liquid assets include cash, stocks, bonds, mutual funds, retirement accounts such as IRAs and 401(k)s, dividends from tax-deferred annuities, and collectibles like art, rare coins, and stamp collections.³ Use current market value for each category, and report both your assets and your spouse’s.

Real Property

Report real property at current market value minus any outstanding mortgage or lien. The form lists second homes, vacation homes, rental property, and farms or ranches as reportable.³ Burial plots are excluded, and depending on your situation, one primary residence and one vehicle can be excluded too. If you’re entering institutional (inpatient) care, the excluded residence and vehicle are your spouse’s or dependent’s, not yours.⁴

Deductible Expenses

Deductions matter. The VA subtracts them from your income (and later your assets) when it decides what you can afford, so leaving them off inflates your copayment. Deductible expenses include your mortgage or rent, one vehicle payment, food costs for the household, education expenses for you or your dependents, court-ordered payments such as alimony or child support, utilities and homeowner’s insurance, out-of-pocket medical costs not covered by other insurance, health insurance premiums, and taxes paid on income and property.⁴ Prepaid funeral or burial arrangements for you, your spouse, or a dependent are also deductible.³

How Your Answers Become a Copayment

There is no flat extended care rate. Your copayment is driven by “available resources,” and the formula changes at the six-month mark.

For the first 180 days of care, available resources equal your household income minus a veteran’s allowance, a spousal allowance, and your deductible expenses. Your assets do not enter the calculation during this initial period.⁴

Starting on day 181, the VA adds your liquid assets, fixed assets, and income together, then subtracts the veteran’s allowance, spousal allowance, a spousal resource protection amount, and (if your spouse or dependents still live in the community) your deductible living expenses. This is where an unreported brokerage account or a second property can suddenly change your bill.

Whatever the formula produces, your first 21 days of extended care in any 12-month period are copay-free. The clock starts the first day the VA provides you with extended care, and copayments only begin on day 22.⁵ If you’re legally separated from your spouse, the VA leaves your spouse’s income, expenses, and assets out of the calculation entirely.⁴

Where To Submit the Form

Return the completed 10-10EC and your supporting documents to the Social Work staff at your local VA medical facility. It is not mailed to a central processing office; it stays with the facility where you’re receiving or applying for care.³ Download a blank form at va.gov/forms/10-10ec/ or pick one up from the administrative offices at any VA medical center.

Bring the paperwork behind your figures: W-2s, 1099-INT statements, Social Security benefit letters, property tax records, mortgage statements. Staff verify the numbers you’ve entered, and mismatches slow the process. Ask for a receipt or written confirmation once the form is accepted.

What Happens After You Submit

Social Work staff review the financial information and counsel you (or someone you’ve designated with power of attorney) on your estimated monthly copayment.³ The counseling session walks through the numbers so you understand your daily rate before care starts or shortly after.

The VA then sends a notification letter with your assigned copayment tier and the daily rate for your specific type of extended care. Those daily rates produce your monthly billing statements. If your finances change afterward — a job loss, a spouse’s death, a large medical expense — tell the Social Work office. The VA can recalculate.

If the Copayment Is Unaffordable

Two different VA processes handle affordability problems, and they solve different problems.

Waiver of Copay Debt You Already Owe

If bills have already piled up, submit a Financial Status Report (VA Form 5655) requesting a waiver of all or part of the balance. You can file online through the VA’s “Request help with copay bills” tool, or mail or hand-deliver the form with a letter explaining your situation. Act within 30 days of receiving a bill to avoid late charges, interest, and collection fees.⁶

Hardship Determination for Future Copays

If your income has dropped to where future copays are out of reach, request a hardship determination using VA Form 10-10HS. Submit it with a letter explaining your circumstances to the business office or health administration office at your nearest VA medical center. Qualifying events include job loss, a sudden income drop, or a spike in out-of-pocket family health care costs. If approved, the VA moves you to a higher priority group and exempts you from copayments for the rest of the calendar year. Pharmacy medication copays are not covered by this exemption.⁶

Report Accurately

Every figure on the form must match your actual records. The VA cross-references what you report against federal databases, and discrepancies trigger scrutiny. Underreporting income or hiding assets can lead to a reassessment at a higher rate, retroactive billing for the difference, or denial of benefits.

The exposure runs further than corrected bills. Knowingly providing false information on a federal form violates 18 U.S.C. 1001, which carries a fine and up to five years of imprisonment.⁷ Separately, under 38 CFR 42.3, the VA can impose civil penalties of up to $14,308 per false claim or false written statement.⁸ The deductions and allowances the form permits are generous enough that honest reporting usually produces a manageable rate.

1
eCFR. 38 CFR 17.111 – Copayments for Extended Care Services
2
Veterans Affairs. Your Health Care Costs
3
U.S. Department of Veterans Affairs. Instructions for Completing Application for Extended Care Services
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eCFR. 38 CFR 17.111 – Copayments for Extended Care Services
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Veterans Affairs. Current VA Health Care Copay Rates
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Veterans Affairs. Request VA Financial Hardship Assistance
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Office of the Law Revision Counsel. 18 US Code 1001 – Statements or Entries Generally
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eCFR. 38 CFR 42.3 – Basis for Civil Penalties and Assessments