Items 1 to 4: State home and contacts
The State home's name, address and phone, the State representative and State home administrator with phone, fax and email, and checkboxes for the domiciliary, nursing home and adult day health care programs.
10-0430
Application for Assistance for Hiring and Retaining Nurses at State Homes
- Agency
- VA
- Revision
- May 2017
- Fillable fields
- 23
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-0430: Application for Assistance for Hiring and Retaining Nurses at State Homes
VA Form 10-0430 is the U.S. Department of Veterans Affairs Application for Assistance for Hiring and Retaining Nurses at State Homes. A State home uses it to ask VA for payment toward an employee incentive program aimed at a nursing shortage at the home. The Privacy Act statement on the form says the information is used to authorize the expenditure of funds to assist State Veterans Homes in the hiring and retention of nurses and the reduction of nursing shortages in State homes. VA's form page lists it under VHA.
The form is two pages. Page 1 asks for the State home and its contacts, the per diem programs it takes part in, the nursing shortage, the incentive program and its cost, the amount applied for, matching funds, retention measures and any employee refunds, then the State representative's signature. Page 2 holds a For VA Use Only block, the mailing address and the Privacy Act statement. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-0430
Items 5 to 7: shortage and incentive program
A description of the nursing shortage, which the form says is to be documented by credible evidence such as State home records establishing vacancies or supporting the need to utilize overtime. Then the employee incentive program, its cost, and how and how fast it would eliminate the shortage.
Item 8: amount applied for
The form says the amount is not to exceed 2 percent of the total per diem payments estimated by VA to be made to the State home during the fiscal year for adult day health care, domiciliary care and nursing home care.
Item 9: matching funds
The form says at least 50% of the funding for the employee incentive program must be from funds not provided by VA. It asks for the State budget official's letter, plus a copy of the act if the certification is based on one.
Items 10 and 11: retention and refunds
Measures to ensure a person receiving incentive benefits works at the State home as a nurse for a period commensurate with the benefits, and a yes or no question on refunds received from an employee in breach of an assistance agreement.
Items 12 and 13, and page 2
The State representative's signature in ink and the date. Page 2 holds the For VA Use Only block, the submission address and the Privacy Act statement.
How to complete VA Form 10-0430
- 1
Enter the State home and contacts
Fill in Items 1 to 3 and include a copy of the State representative's delegation of authority, as Item 2 asks.
- 2
Describe the shortage and the program
Check the per diem programs in Item 4, then answer Items 5 to 7. Each of those items says to attach documentation.
- 3
Enter the amount and matching funds
Give the amount applied for in Item 8 and describe matching funds in Item 9, attaching the State budget official's letter and any act it relies on.
- 4
Answer Items 10 and 11
Describe the retention measures and answer the refund question. If the answer is yes, the form asks for the circumstances and documentation.
- 5
Sign, date and mail it
The State representative signs Item 12 in ink and dates Item 13. Page 2 says to submit the application with supporting documentation to VA Geriatrics and Extended Care in Washington.
Why fill Form 10-0430 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it
Mailing address
Department of Veterans Affairs, Geriatrics and Extended Care, 810 Vermont Avenue, N.W., Washington DC 20420. The form says to submit the application with supporting documentation.
Privacy Act
The information is collected under Title 38, Part II, Sections 1710 and 1730. The form says it is voluntary, but failure to provide it will delay or prevent approval.
Edition
The current edition is dated MAY 2017 and has two pages.
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10-0388-1
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Who uses VA Form 10-0430?
The form names these people and offices.
Official sources and the blank
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Questions about Form 10-0430
Who fills in VA Form 10-0430?
It is completed for a State home. Item 12 is the signature of the State representative, the official designated under State authority for matters relating to payments under 38 CFR Part 53, signed in ink.
How much can a State home apply for?
Item 8 says the amount applied for is not to exceed 2 percent of the total per diem payments estimated by VA to be made to the State home during the fiscal year for adult day health care, domiciliary care and nursing home care.
Does the State need matching funds?
Item 9 says at least 50% of the funding for the employee incentive program must be from funds not provided by VA, and asks for a letter from an authorized State budget official certifying the funds.
What evidence of a nursing shortage does the form ask for?
Item 5 asks for credible evidence, such as State home records establishing vacancies or State home records supporting the need to utilize overtime, with documentation attached.
Where is VA Form 10-0430 sent?
Page 2 lists Department of Veterans Affairs, Geriatrics and Extended Care, 810 Vermont Avenue, N.W., Washington DC 20420.
What goes in the For VA Use Only block?
VA enters the VA medical center of jurisdiction for the State home and the maximum amount for which the State home is eligible.