How to complete a VA form 10 10EZ (Step by Step)

To complete a VA Form 10-10EZ, you will need to provide the following information:

• General information
  • Veteran’s name
  • Preferred name
  • Mother’s maiden name
  • Birth sex
  • Self-identified gender identity
  • Whether you are Spanish, Hispanic, or Latino
  • Race: Asian, American Indian or Alaska native, Black or African American, White, Native Hawaiian or other Pacific Islander
  • Social Security number
  • VA claim number
  • Date of birth
  • Place of birth
  • Religion
  • Permanent Address - street, city, state, zip code, county
  • Telephone number
  • Email address
  • Residential address
  • Type of benefits applying for
  • Current marital status
  • Next of kin name, address, relationship, phone number
  • Designee to receive possession of personal property left on premises under VA control after departure or time of death
  • Whether you are enrolling to obtain minimum essential coverage under the Affordable Care Act
  • Preferred VA Medical Center or Outpatient Clinic
  • Whether you would like for VA to contact you to schedule your first appointment 
• Military Service Information
  • Last branch of service 
  • Last entry date
  • Future discharge date
  • Last discharge date
  • Discharge type
  • Military service number
  • Military history
• Insurance Information
  • Health insurance company name, address, telephone number
  • Name of policy holder
  • Policy number
  • Group code
  • Whether you are eligible for Medicaid
  • Whether you are enrolled in Medicare hospital insurance Part A
• Dependent Information
  • Spouse’s name
  • Spouses’ social security number
  • Spouse’s date of birth
  • Spouse self-identified gender identity
  • Date of marriage
  • Spouse’s address and phone number
  • Child’s name
  • Child’s date of birth
  • Child’s social security number
  • Date child became your dependant 
  • Child’s relationship to you
  • Whether child was permanently and totally disabled before the age of 18
  • Whether child is between 18 and 23 years of age and attended school last calendar year
  • Expenses paid by your dependent child for college, vocational rehabilitation, or training 
• Employment Information
  • Veteran’s Employment status
  • Date of retirement
  • Company name
  • Company address
  • Company phone number
• Previous Calendar Year Annual Income of Veteran, Spouse, and Dependent Children
  • Gross annual income from employment excluding income from farm, ranch, property or business
  • Net income from farm, ranch, property, or business
  • Other income amounts
• Previous Calendar Year Deductible Expenses
  • Total medical expenses paid by you or your spouse for which you did not receive monetary compensation
  • Amount you paid last calendar year for funeral and burial expenses for your deceased spouse or dependent child
  • Amount you paid last year for your college or vocational educational expenses
• Consent to Copays and to Receive Communications
• Signature