VA Form 10-10068

Camp Lejeune Family Member Program Application

Toxic Exposure / PACT ActOfficial VA form on VA.gov

Who fills it

dependent

Journey phase

VA Healthcare

Estimated time

30-45 minutes.

When to file

Apply as soon as you believe you have a covered condition. There is no deadline, but earlier filing provides earlier access to care.

You are the spouse, child, or other family member of a veteran or service member who LIVED AT Camp Lejeune between August 1953 and December 1987, and you have a covered condition caused by contaminated water.

Gather before you start

—Documentation of residence at Camp Lejeune 1953-1987 (housing orders, utility bills, school records, PCS orders showing MCB Camp Lejeune)

—Medical records confirming one of the 15 covered conditions

—Veteran/service member's service records showing assignment at Camp Lejeune

—Your relationship to the veteran and proof (birth cert, marriage cert)

Attach with the form

—Proof of residence at Camp Lejeune during the covered period

—Medical records confirming covered condition diagnosis

—Veteran service records showing Camp Lejeune assignment

—Proof of relationship to the veteran

Section I - Applicant Identification

1 field

Blocks 1-6Your name, SSN, DOB, address, relationship to veteranPII

YOU are the applicant (family member), not the veteran. Relationship types: spouse, child, parent, or other dependent who LIVED on-base at Camp Lejeune during the covered period.

Example

(your legal name, SSN, DOB, relationship)

Common mistakes

Veterans applying through this form for themselves - veterans who served at Camp Lejeune apply through VA Form 21-526EZ for disability compensation, not this form.
Applying for a non-covered condition - 15 specific conditions qualify; verify at va.gov before filing.

Section II - Camp Lejeune Residence

1 field · 1 citation

Blocks 7-12Dates of residence at Camp Lejeune and documentation

Exact dates you lived on Marine Corps Base Camp Lejeune. Include the specific housing area or address if known (Hadnot Point, Tarawa Terrace, Holcomb Boulevard, etc. - these had different water supplies). The minimum required residency is 30 days during the covered period.

Example

e.g., Resided at Camp Lejeune from 07/1968 to 03/1971 in family housing at Tarawa Terrace. PCS orders of veteran (Cpl John Smith) show MCB Camp Lejeune assignment 06/1968-04/1971.

Common mistakes

Not knowing the specific housing areas matter - Hadnot Point and Tarawa Terrace had the contaminated water supplies; not all Camp Lejeune housing areas were affected equally.
Missing the 30-day minimum - occasional visits or temporary residence of less than 30 days does not qualify.

Authority

38 CFR 17.400 - 15 covered conditions for family members at Lejeune 1953–1987.

Section III - Covered Condition

1 field

Blocks 13-16Which covered condition are you seeking care for?

The 15 covered conditions: (1) Esophageal cancer, (2) Breast cancer, (3) Kidney cancer, (4) Multiple myeloma, (5) Renal toxicity, (6) Female infertility, (7) Scleroderma, (8) Non-Hodgkin's lymphoma, (9) Bladder cancer, (10) Leukemia, (11) Miscarriage, (12) Hepatic steatosis (fatty liver), (13) Neurobehavioral effects, (14) Myelodysplastic syndromes, (15) Prostate cancer. Provide your diagnosis and when first diagnosed.

Example

e.g., Breast cancer, first diagnosed 2018, treated by Dr. Smith at Banner Cancer Center.

Common mistakes

Confusing family member CLFMP program with veteran compensation claims - different programs with different forms.
Applying for a condition not on the covered list - only these 15 conditions are covered under this program.

Section IV - Certification

1 field

Blocks 17-18Applicant signature and datePII

Sign and date. Mail to: VA HAC, P.O. Box 469064, Denver CO 80246.

Example

(your signature/date)

Common mistakes

Mailing to the local VAMC instead of Denver - CLFMP is managed centrally.

Statutory & regulatory authority

38 CFR 17.400 - 15 covered conditions for family members at Lejeune 1953–1987.

38 CFR 3.309(f) - Presumptive conditions for veterans/families at Camp Lejeune 1953–1987.

38 USC 1787 - Health care for family members who resided at Camp Lejeune during the contamination period (1953-1987).

VA Form 10-10068

Camp Lejeune Family Member Program Application

Toxic Exposure / PACT ActOfficial VA form on VA.gov

Who fills it

dependent

Journey phase

VA Healthcare

Estimated time

30-45 minutes.

When to file

Apply as soon as you believe you have a covered condition. There is no deadline, but earlier filing provides earlier access to care.

Gather before you start

—Documentation of residence at Camp Lejeune 1953-1987 (housing orders, utility bills, school records, PCS orders showing MCB Camp Lejeune)

—Medical records confirming one of the 15 covered conditions

—Veteran/service member's service records showing assignment at Camp Lejeune

—Your relationship to the veteran and proof (birth cert, marriage cert)

Attach with the form

—Proof of residence at Camp Lejeune during the covered period

—Medical records confirming covered condition diagnosis

—Veteran service records showing Camp Lejeune assignment

—Proof of relationship to the veteran

Section I - Applicant Identification

1 field

Blocks 1-6Your name, SSN, DOB, address, relationship to veteranPII

YOU are the applicant (family member), not the veteran. Relationship types: spouse, child, parent, or other dependent who LIVED on-base at Camp Lejeune during the covered period.

Example

(your legal name, SSN, DOB, relationship)

Common mistakes

Veterans applying through this form for themselves - veterans who served at Camp Lejeune apply through VA Form 21-526EZ for disability compensation, not this form.
Applying for a non-covered condition - 15 specific conditions qualify; verify at va.gov before filing.

Section II - Camp Lejeune Residence

1 field · 1 citation

Blocks 7-12Dates of residence at Camp Lejeune and documentation

Example

e.g., Resided at Camp Lejeune from 07/1968 to 03/1971 in family housing at Tarawa Terrace. PCS orders of veteran (Cpl John Smith) show MCB Camp Lejeune assignment 06/1968-04/1971.

Common mistakes

Not knowing the specific housing areas matter - Hadnot Point and Tarawa Terrace had the contaminated water supplies; not all Camp Lejeune housing areas were affected equally.
Missing the 30-day minimum - occasional visits or temporary residence of less than 30 days does not qualify.

Authority

38 CFR 17.400 - 15 covered conditions for family members at Lejeune 1953–1987.

Section III - Covered Condition

1 field

Blocks 13-16Which covered condition are you seeking care for?

Example

e.g., Breast cancer, first diagnosed 2018, treated by Dr. Smith at Banner Cancer Center.

Common mistakes

Confusing family member CLFMP program with veteran compensation claims - different programs with different forms.
Applying for a condition not on the covered list - only these 15 conditions are covered under this program.

Section IV - Certification

1 field

Blocks 17-18Applicant signature and datePII

Sign and date. Mail to: VA HAC, P.O. Box 469064, Denver CO 80246.

Example

(your signature/date)

Common mistakes

Mailing to the local VAMC instead of Denver - CLFMP is managed centrally.

Statutory & regulatory authority

38 CFR 17.400 - 15 covered conditions for family members at Lejeune 1953–1987.

38 CFR 3.309(f) - Presumptive conditions for veterans/families at Camp Lejeune 1953–1987.

38 USC 1787 - Health care for family members who resided at Camp Lejeune during the contamination period (1953-1987).

VA Form 10-10068

Camp Lejeune Family Member Program Application

Toxic Exposure / PACT ActOfficial VA form on VA.gov

Who fills it

dependent

Journey phase

VA Healthcare

Estimated time

30-45 minutes.

When to file

Apply as soon as you believe you have a covered condition. There is no deadline, but earlier filing provides earlier access to care.

Gather before you start

—Documentation of residence at Camp Lejeune 1953-1987 (housing orders, utility bills, school records, PCS orders showing MCB Camp Lejeune)

—Medical records confirming one of the 15 covered conditions

—Veteran/service member's service records showing assignment at Camp Lejeune

—Your relationship to the veteran and proof (birth cert, marriage cert)

Attach with the form

—Proof of residence at Camp Lejeune during the covered period

—Medical records confirming covered condition diagnosis

—Veteran service records showing Camp Lejeune assignment

—Proof of relationship to the veteran

Section I - Applicant Identification

1 field

Blocks 1-6Your name, SSN, DOB, address, relationship to veteranPII

YOU are the applicant (family member), not the veteran. Relationship types: spouse, child, parent, or other dependent who LIVED on-base at Camp Lejeune during the covered period.

Example

(your legal name, SSN, DOB, relationship)

Common mistakes

Veterans applying through this form for themselves - veterans who served at Camp Lejeune apply through VA Form 21-526EZ for disability compensation, not this form.
Applying for a non-covered condition - 15 specific conditions qualify; verify at va.gov before filing.

Section II - Camp Lejeune Residence

1 field · 1 citation

Blocks 7-12Dates of residence at Camp Lejeune and documentation

Example

e.g., Resided at Camp Lejeune from 07/1968 to 03/1971 in family housing at Tarawa Terrace. PCS orders of veteran (Cpl John Smith) show MCB Camp Lejeune assignment 06/1968-04/1971.

Common mistakes

Not knowing the specific housing areas matter - Hadnot Point and Tarawa Terrace had the contaminated water supplies; not all Camp Lejeune housing areas were affected equally.
Missing the 30-day minimum - occasional visits or temporary residence of less than 30 days does not qualify.

Authority

38 CFR 17.400 - 15 covered conditions for family members at Lejeune 1953–1987.

Section III - Covered Condition

1 field

Blocks 13-16Which covered condition are you seeking care for?

Example

e.g., Breast cancer, first diagnosed 2018, treated by Dr. Smith at Banner Cancer Center.

Common mistakes

Confusing family member CLFMP program with veteran compensation claims - different programs with different forms.
Applying for a condition not on the covered list - only these 15 conditions are covered under this program.

Section IV - Certification

1 field

Blocks 17-18Applicant signature and datePII

Sign and date. Mail to: VA HAC, P.O. Box 469064, Denver CO 80246.

Example

(your signature/date)

Common mistakes

Mailing to the local VAMC instead of Denver - CLFMP is managed centrally.

Statutory & regulatory authority

38 CFR 17.400 - 15 covered conditions for family members at Lejeune 1953–1987.

38 CFR 3.309(f) - Presumptive conditions for veterans/families at Camp Lejeune 1953–1987.

38 USC 1787 - Health care for family members who resided at Camp Lejeune during the contamination period (1953-1987).

VA Form 10-10068

Camp Lejeune Family Member Program Application

Toxic Exposure / PACT ActOfficial VA form on VA.gov

Who fills it

dependent

Journey phase

VA Healthcare

Estimated time

30-45 minutes.

When to file

Apply as soon as you believe you have a covered condition. There is no deadline, but earlier filing provides earlier access to care.

Gather before you start

—Documentation of residence at Camp Lejeune 1953-1987 (housing orders, utility bills, school records, PCS orders showing MCB Camp Lejeune)

—Medical records confirming one of the 15 covered conditions

—Veteran/service member's service records showing assignment at Camp Lejeune

—Your relationship to the veteran and proof (birth cert, marriage cert)

Attach with the form

—Proof of residence at Camp Lejeune during the covered period

—Medical records confirming covered condition diagnosis

—Veteran service records showing Camp Lejeune assignment

—Proof of relationship to the veteran

Section I - Applicant Identification

1 field

Blocks 1-6Your name, SSN, DOB, address, relationship to veteranPII

YOU are the applicant (family member), not the veteran. Relationship types: spouse, child, parent, or other dependent who LIVED on-base at Camp Lejeune during the covered period.

Example

(your legal name, SSN, DOB, relationship)

Common mistakes

Veterans applying through this form for themselves - veterans who served at Camp Lejeune apply through VA Form 21-526EZ for disability compensation, not this form.
Applying for a non-covered condition - 15 specific conditions qualify; verify at va.gov before filing.

Section II - Camp Lejeune Residence

1 field · 1 citation

Blocks 7-12Dates of residence at Camp Lejeune and documentation

Example

e.g., Resided at Camp Lejeune from 07/1968 to 03/1971 in family housing at Tarawa Terrace. PCS orders of veteran (Cpl John Smith) show MCB Camp Lejeune assignment 06/1968-04/1971.

Common mistakes

Not knowing the specific housing areas matter - Hadnot Point and Tarawa Terrace had the contaminated water supplies; not all Camp Lejeune housing areas were affected equally.
Missing the 30-day minimum - occasional visits or temporary residence of less than 30 days does not qualify.

Authority

38 CFR 17.400 - 15 covered conditions for family members at Lejeune 1953–1987.

Section III - Covered Condition

1 field

Blocks 13-16Which covered condition are you seeking care for?

Example

e.g., Breast cancer, first diagnosed 2018, treated by Dr. Smith at Banner Cancer Center.

Common mistakes

Confusing family member CLFMP program with veteran compensation claims - different programs with different forms.
Applying for a condition not on the covered list - only these 15 conditions are covered under this program.

Section IV - Certification

1 field

Blocks 17-18Applicant signature and datePII

Sign and date. Mail to: VA HAC, P.O. Box 469064, Denver CO 80246.

Example

(your signature/date)

Common mistakes

Mailing to the local VAMC instead of Denver - CLFMP is managed centrally.

Statutory & regulatory authority

38 CFR 17.400 - 15 covered conditions for family members at Lejeune 1953–1987.

38 CFR 3.309(f) - Presumptive conditions for veterans/families at Camp Lejeune 1953–1987.

38 USC 1787 - Health care for family members who resided at Camp Lejeune during the contamination period (1953-1987).