A Vet 4 Vets
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Financial Assistance
Application Forms
The following forms are used for applying for financial assistance. Each form includes a brief description and a link to download or complete the form online.
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VA Form 10-10EZ - Health Benefits Application
Apply for VA health care benefits using this form. It is required to establish eligibility for many VA assistance programs.
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VA Form 10-10HS - Request for Hardship Determination
Use this form to request a hardship determination if you’re having financial difficulty paying VA copays.
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VA Form 5655 - Financial Status Report
This form is required to assess financial need for repayment plans, waivers, or financial relief.
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VA Form 1100 - Agreement to Pay Indebtedness
Used when entering into a repayment agreement with the VA regarding debt owed.
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VA Form 4-5655 - Financial Status Report for Loan Programs
This version is used for VA Loan-related financial hardship or repayment agreements.
Helpful Resources
These links provide more information and assistance related to financial help through the VA.