Items 1 to 3F: general information
The Veteran's name, Social Security number, permanent address with city, state and 9 digit ZIP code, county, and home and cellular telephone numbers.
10-10HS
Request for Hardship Determination
- Agency
- VA
- Revision
- July 2024
- Fillable fields
- 27
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10HS: Request for Hardship Determination
VA Form 10-10HS is the U.S. Department of Veterans Affairs Request for Hardship Determination, listed under VHA on VA's page. The form says it is used to determine whether the Veteran's projected income for the current year will be substantially below the VA means test threshold due to a loss of income or an increase in allowable deductible expenses.
The form says Veterans determined to have a financial hardship will be exempt from payment of hospital and medical care copays and qualify for enrollment in Priority Group 5, unless otherwise eligible for enrollment in a higher priority, from the date of request through the last day of the same calendar year.
The PDF has two pages. Page 1 holds the Veteran's general information, the reason for the request, projected household income and deductible expenses, and the Veteran's signature. Page 2 is marked to be completed by VA. 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 10-10HS
Reason or circumstance for the request
Checkboxes for each reason, with space below to explain. The form says to provide an explanation, as needed, and attach documentation supporting the request.
Projected income and deductible expenses
For the current calendar year: household income, which includes gross income from employment, net income from farm or ranch, and other income amounts, and deductible expenses, which include non-reimbursed medical expenses, funeral and burial expenses and expenses for the Veteran's education.
Notices, signature and date
The VA burden statement, the Privacy Act information, the Veteran's signature with the date in MM/DD/YYYY format, and the penalty statement for willfully submitting false statements or evidence.
Page 2: VA's determination
Hardship granted yes or no, the date the Veteran's electronic record was updated, the VHA staff signature, comments, and the date the Veteran was notified.
How to complete VA Form 10-10HS
- 1
Fill in the general information
Enter the Veteran's name, Social Security number, permanent address, county and telephone numbers in Items 1 to 3F.
- 2
Check the reasons and explain
Check all that apply. The form says to add an explanation as needed and attach documentation supporting the request.
- 3
Enter projected figures
Give projected household income and deductible expenses for the current calendar year in the Veteran, Spouse and Children columns.
- 4
Sign and date page 1
Sign the Veteran's signature line and enter the date in MM/DD/YYYY format.
- 5
Leave page 2 for VA
Page 2 is marked to be completed by VA. It records the decision, the VHA staff signature and the date the Veteran was notified.
Why fill Form 10-10HS 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
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- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Decision, notices and edition
Where it goes
The form prints no mailing address. Its burden statement lists the VA Reports Clearance Officer email for comments and says: Do not send your completed VA Form 10-10HS to this email address.
If granted
The form notes that the exemption is effective from the date the Veteran submitted the request until the last day of the calendar year in which the request was made.
If not granted
The NO box on page 2 says to state the reason not granted in comments. The form then says: If hardship not granted, provide Veteran with VA Form 10-0998, Your Rights To Seek Further Review Of Our Health Care Benefits Decision.
Burden
OMB Control No. 2900-0091, which expires 07/31/2027. The burden is estimated to average 15 minutes per respondent, per year.
Edition
The PDF footer prints JUL 2024. VA's form page lists a revision date of August 2021.
Related forms
Who uses VA Form 10-10HS?
The form splits the work between the Veteran on page 1 and VA on page 2.
Official sources and the blank
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Questions about Form 10-10HS
What is VA Form 10-10HS used for?
The form says it is used to determine whether the Veteran's projected income for the current year will be substantially below the VA means test threshold due to a loss of income or an increase in allowable deductible expenses.
What does the form say a hardship determination covers?
The form says Veterans determined to have a financial hardship will be exempt from payment of hospital and medical care copays and qualify for enrollment in Priority Group 5, unless otherwise eligible for a higher priority, from the date of request through the last day of the same calendar year.
Which year's income does VA Form 10-10HS ask for?
The current calendar year. The table asks for projected household income and deductible expenses for the Veteran, spouse and children.
Which reasons can be checked?
Reduction of household income, paid out of pocket medical expenses, increase in number of dependents, moved to a higher cost of living area, and other, with space to explain.
Who completes page 2?
Page 2 is marked to be completed by VA. It holds the hardship decision, the VHA staff signature, comments and the date the Veteran was notified.
What if the hardship is not granted?
Page 2 says to state the reason in comments and to provide the Veteran with VA Form 10-0998, Your Rights To Seek Further Review Of Our Health Care Benefits Decision.
Is providing the information voluntary?
The Privacy Act notice says providing the requested information is voluntary, but if any or all of it is not provided, it may delay or result in denial of the request for health care benefits.