VA Form 21-4502 Application for Automobile or Other Conveyance and Adaptive Equipment

VA Form 21-4502 is a United States Department of Veterans Affairs form also known as the "Application For Automobile Or Other Conveyance And Adaptive Equipment".

The latest fillable PDF version of the VA 21-4502 was issued on February 1, 2015 and can be downloaded down below or found on the Veterans Affairs Forms website.

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OMB Control No. 2900-0067
Respondent Burden: 15 Minutes
Expiration Date: 01/31/2018
APPLICATION FOR AUTOMOBILE OR OTHER CONVEYANCE
AND ADAPTIVE EQUIPMENT (UNDER 38 U.S.C. 3901-3904)
1A.VA FILE NUMBER
1B. VETERAN'S SOCIAL SECURITY NUMBER
NOTE: Please read the "Information and Instructions" on Page 3 before you fill out this form.
(To be completed by veteran or serviceperson)
SECTION I - APPLICATION
NOTE: A serviceperson planning early release should give both present military address and planned address following release from active duty, in Items 3A and 3B.
2. FIRST NAME - MIDDLE INITIAL - LAST NAME
(No. and Street or rural route, City or P.O., State and Zip Code)
3A. CURRENT ADDRESS
Number and Street
or Rural Route, P.O.
Box
Apt./Unit Number
City, State, ZIP Code
Country
(No. and Street or rural route, City or P.O., State and Zip Code)
3B. SERVICEPERSON'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY
Number and Street
or Rural Route, P.O.
Box
Apt./Unit Number
City, State, ZIP Code
Country
4. BRANCH OF SERVICE
5. ARE YOU ON ACTIVE DUTY?
AIR
MARINE
COAST
OTHER
ARMY
NAVY
YES
NO
(Specify)
FORCE
CORPS
GUARD
6A. PLACE OF ENTRY INTO ACTIVE DUTY
6B. DATE OF ENTRY
Month
Day
Year
(If applicable)
6C. PLACE OF RELEASE FROM ACTIVE DUTY
6D. DATE OF RELEASE
Month
Day
Year
(If known)
7B. DATE YOU APPLIED
8. LOCATION OF VA OFFICE THAT HAS YOUR FILE
7A. HAVE YOU APPLIED FOR VA DISABILITY
(If "Yes,"give place)
COMPENSATION?
Month
Day
Year
YES
NO
(Check one)
9. TYPE OF CONVEYANCE APPLIED FOR
STATION
OTHER
AUTOMOBILE
VAN
TRUCK
WAGON
(Specify)
(This is a once-per-lifetime grant)
10. HAVE YOU PREVIOUSLY APPLIED FOR AN AUTOMOBILE OR OTHER CONVEYANCE?
(If "Yes,"give date and place)
YES
NO
Month
Day
Year
I hereby apply for the conveyance checked in Item 9 above and the equipment required because of my disability. I agree that before operating the vehicle I shall
hereafter apply to the proper authority for the necessary license to operate it. If I am unable to qualify for a license, I certify that a person licensed to operate a similar
vehicle in the state of my residence will operate the vehicle for me. I further certify that VA has not previously paid an automobile grant on my behalf.
(Include Area Code)
13. TELEPHONE NUMBERS
11. SIGNATURE OF VETERAN OR SERVICEPERSON
12. DATE SIGNED
Month
Day
Year
A. DAYTIME
B. EVENING
(
)
(
)
VA FORM
21-4502
SUPERSEDES VA FORM 21-4502, JUL 2008,
PAGE 1
FEB 2015
WHICH WILL NOT BE USED.
OMB Control No. 2900-0067
Respondent Burden: 15 Minutes
Expiration Date: 01/31/2018
APPLICATION FOR AUTOMOBILE OR OTHER CONVEYANCE
AND ADAPTIVE EQUIPMENT (UNDER 38 U.S.C. 3901-3904)
1A.VA FILE NUMBER
1B. VETERAN'S SOCIAL SECURITY NUMBER
NOTE: Please read the "Information and Instructions" on Page 3 before you fill out this form.
(To be completed by veteran or serviceperson)
SECTION I - APPLICATION
NOTE: A serviceperson planning early release should give both present military address and planned address following release from active duty, in Items 3A and 3B.
2. FIRST NAME - MIDDLE INITIAL - LAST NAME
(No. and Street or rural route, City or P.O., State and Zip Code)
3A. CURRENT ADDRESS
Number and Street
or Rural Route, P.O.
Box
Apt./Unit Number
City, State, ZIP Code
Country
(No. and Street or rural route, City or P.O., State and Zip Code)
3B. SERVICEPERSON'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY
Number and Street
or Rural Route, P.O.
Box
Apt./Unit Number
City, State, ZIP Code
Country
4. BRANCH OF SERVICE
5. ARE YOU ON ACTIVE DUTY?
AIR
MARINE
COAST
OTHER
ARMY
NAVY
YES
NO
(Specify)
FORCE
CORPS
GUARD
6A. PLACE OF ENTRY INTO ACTIVE DUTY
6B. DATE OF ENTRY
Month
Day
Year
(If applicable)
6C. PLACE OF RELEASE FROM ACTIVE DUTY
6D. DATE OF RELEASE
Month
Day
Year
(If known)
7B. DATE YOU APPLIED
8. LOCATION OF VA OFFICE THAT HAS YOUR FILE
7A. HAVE YOU APPLIED FOR VA DISABILITY
(If "Yes,"give place)
COMPENSATION?
Month
Day
Year
YES
NO
(Check one)
9. TYPE OF CONVEYANCE APPLIED FOR
STATION
OTHER
AUTOMOBILE
VAN
TRUCK
WAGON
(Specify)
(This is a once-per-lifetime grant)
10. HAVE YOU PREVIOUSLY APPLIED FOR AN AUTOMOBILE OR OTHER CONVEYANCE?
(If "Yes,"give date and place)
YES
NO
Month
Day
Year
I hereby apply for the conveyance checked in Item 9 above and the equipment required because of my disability. I agree that before operating the vehicle I shall
hereafter apply to the proper authority for the necessary license to operate it. If I am unable to qualify for a license, I certify that a person licensed to operate a similar
vehicle in the state of my residence will operate the vehicle for me. I further certify that VA has not previously paid an automobile grant on my behalf.
(Include Area Code)
13. TELEPHONE NUMBERS
11. SIGNATURE OF VETERAN OR SERVICEPERSON
12. DATE SIGNED
Month
Day
Year
A. DAYTIME
B. EVENING
(
)
(
)
VA FORM
21-4502
SUPERSEDES VA FORM 21-4502, JUL 2008,
PAGE 1
FEB 2015
WHICH WILL NOT BE USED.
SECTION II - CERTIFICATE OF ELIGIBILITY
(To be completed by VA)
(Check appropriate box(es))
QUALIFYING DISABILITIES
14A. LOSS OF FOOT
14B. LOSS OF HAND
14C. PERMANENT LOSS OF USE OF FOOT
14D. PERMANENT LOSS OF USE OF HAND
RIGHT
LEFT
BOTH
RIGHT
LEFT
BOTH
RIGHT
LEFT
BOTH
RIGHT
LEFT
BOTH
17. AMYOTROPHIC LATERAL SCLEROSIS
15. PERMANENT IMPAIRMENT OF VISION
16. SEVERE BURN INJURY
(ALS)
CENTRAL VISUAL ACUITY 20/200 OR LESS IN THE BETTER EYE
YES
NO
WITH CORRECTIVE GLASSES
YES
NO
CONTRACTION OF THE PERIPHERAL FIELD OF VISION TO 20
DEGREES OR LESS IN THE BETTER EYE
18. Authorization for Allowance for Automobile or Other Conveyance: The above-named applicant is eligible under 38 U.S.C. 3901-3904 to purchase the
automobile or conveyance shown in Item 9, subject to certain payment limitations. VA cannot pay more than the rate in effect when VA receives the claim for payment
from the seller. The allowance includes applicable taxes when included in the purchase price. The allowance does not include payment for any adaptive equipment
specified for the qualifying disabilities.
Adaptive Equipment: The cost of adaptive equipment and its installation may be reimbursed. Adaptive equipment is not provided if the claimant is blind, requires a
driver, or doesn't have a valid State driver's license or learner's permit. See the attached list for the adaptive equipment that is authorized for the qualifying disabilities
shown above. All additional add-on equipment must be approved by VA.
I CERTIFY THAT the veteran has not previously received an allowance for automobile or other conveyance under 38 U.S.C. 3901-3904.
19. NAME AND LOCATION OF VA OFFICE
20A. SIGNATURE AND TITLE OF CERTIFYING OFFICIAL
20B. DATE SIGNED
(To be completed by veteran or serviceperson)
SECTION III - RECEIPT FOR AUTOMOBILE OR OTHER CONVEYANCE AND ADAPTIVE EQUIPMENT
21. MAKE AND MODEL
22. YEAR
23. VEHICLE IDENTIFICATION NO. (VIN)
24. TOTAL PURCHASE PRICE
25. DATE OF SALE
$
26A. I WILL OPERATE THIS VEHICLE
26B. I HAVE A VALID STATE DRIVER'S LICENSE OR LEARNER'S PERMIT
YES
NO
YES
NO
27. NAME OF SELLER
28. ADDRESS OF SELLER
I hereby acknowledge receipt of the automobile or other conveyance with the adaptive equipment specified on attached invoice.
29A. SIGNATURE OF VETERAN OR SERVICEPERSON
29B. DATE OF RECEIPT
PENALTY: The law provides severe penalties, which include fine or imprisonment or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
PAGE 2
VA FORM 21-4502, FEB 2015
INFORMATION AND INSTRUCTIONS
If you have questions about this form, how to fill it out, or about benefits, call VA toll-free at 1-800-827-1000
(If you use a Telecommunications Device for the Deaf (TDD), the federal relay number is 711.)
You may also contact VA by Internet at https://iris.va.gov
A. What are automobile and adaptive equipment benefits and how does VA
C. When should VA Form 21-4502 be submitted?
decide what I will or will not receive?
There is no time limit for filing a claim; however, the claim must be authorized by
VA before you purchase the automobile or conveyance.
1. Allowance towards purchase of a vehicle - Veterans who are receiving
compensation under 38 U.S.C. 1151 for any of the following disabilities are also
D. Instructions to veteran or serviceperson
eligible. This payment is a once-per-lifetime grant, and the amount paid is limited
1. Complete all items of Section I in duplicate and submit both copies to VA. If
by law. Contact VA for the current rate.
you have previously applied for disability compensation, send the form to the VA
regional office where your claims folder is located. If you have not applied for
A veteran or serviceperson must possess one of the following disabilities as a
disability compensation or have not separated from military service, send the form
result of injury or disease incurred or aggravated during active military service:
to the nearest VA regional office.
• loss or permanent loss of use of one or both feet, or
2. VA will determine your eligibility and, if eligibility exists, VA will complete
Section II and return the form to you.
• loss or permanent loss of use of one or both hands, or
• permanent impairment of vision in both eyes with a
3. Purchase a vehicle. When you receive the vehicle and the adaptive equipment
• central visual acuity of 20/200 or less in the better eye with corrective
from the seller, complete Section III.
glasses, or
4. Give the original VA Form 21-4502 to the seller.
• central visual acuity of more than 20/200 if there is a field defect in
which the peripheral field has contracted to such an extent that the
5. Submit any invoices for adaptive equipment and/or installation not included on
widest diameter of visual field has an angular distance no greater
the seller's invoice to the nearest VA health care facility. These invoices,
than 20 degrees in the better eye, or
identified with your full name and VA file number, must show the itemized net
• Severe burn injury: Deep partial thickness or full thickness burns resulting in
cost of any adaptive equipment and installation charges, any unpaid balance, and
scar formation that cause contractures and limit motion of one or more
the make, year and model of the vehicle to which the equipment is added.
extremities or the trunk and preclude effective operation of an automobile, or
• amyotrophic lateral sclerosis (ALS).
E. Instructions to seller
1. Make sure that Section II of VA Form 21-4502 is completed and signed by VA.
Important: Do not purchase a vehicle until authorized by VA. VA is required by
law to pay the benefit to the seller of the vehicle. Payment cannot be made to the
2. Deliver the vehicle, including VA-approved adaptive equipment provided and/
veteran or serviceperson.
or installed by the seller.
2. Adaptive equipment
3. Obtain the original copy of VA Form 21-4502 from the veteran or
A veteran or serviceperson who qualifies for the vehicle allowance also qualifies
serviceperson after he or she has completed Section III.
for adaptive equipment unless he or she is blind, requires a driver, or doesn't have
a valid State driver's license or learner's permit. See the attached list for more
4. Submit the original copy of VA Form 21-4502 and itemized invoice to the VA
information about adaptive equipment. Important: VA will not pay for the
regional office shown in Section II, Attention: Financial Division, for payment.
purchase of add-on adaptive equipment (equipment furnished by someone other
The itemized invoice must include the following:
than the automobile manufacturer) that is not approved by VA. Contact the
nearest VA health care facility for more information on add-on equipment. The
• The net cost of any approved adaptive equipment and installation charges. If
adaptive equipment benefit may be paid more than once, and it may be paid to
certain items of approved adaptive equipment (automatic transmission,
either the seller or the veteran or serviceperson.
power seats, etc.) are included in the purchase price, also submit a copy of
the window sticker.
3. Special drivers training for disabled veterans should contact the nearest VA
health care facility to request this training.
• A list of which adaptive equipment is standard on the vehicle or combined
with other items.
B. What conveyance may be purchased?
• The unpaid balance due on the vehicle which is to be paid by VA.
You may purchase a new or used automobile, truck, station wagon, or certain
other types of conveyance if approved by VA.
• A certification that the amounts billed do not exceed the usual and
customary cost for the purchase and installation of the adaptive equipment.
PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United
States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title
38 USC 5101 (c)(1). The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to
January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered
confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information in order to determine eligibility for automobile or other conveyance and adaptive equipment allowance (38 U.S.C. Chapter 39). Title 38,
United States Code, allows us to ask for this information if this number is not displayed. We estimate that you will need an average of 15 minutes to review the instructions, find the information,
and complete the form. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
PAGE 3
VA FORM 21-4502, FEB 2015
ADAPTIVE EQUIPMENT FOR AUTOMOBILES AND SIMILAR VEHICLES
IMPORTANT
Adaptive equipment for the operation of the vehicle cannot be provided if the veteran or serviceperson is blind, requires a driver because of physical
disability, or does not have a valid State driver's license or learner's permit. The list below shows the equipment that is authorized for the qualifying
disabilities shown in Section II of VA Form 21-4502. Request approval from the nearest VA health care facility for any equipment not shown below, or
if adaptive equipment is required for driver training and testing.
A. BASIC EQUIPMENT
DISABILITY
ADAPTIVE EQUIPMENT
Loss of a foot (including loss of use)...............................
Basic automatic transmission and power brakes
Basic automatic transmission, power steering and power
Loss of both feet (including loss of use)..........................
brakes.
Loss of a hand (including loss of use).............................
Basic automatic transmission and power steering.
Loss of a hand and a foot (including loss of use)............
Basic automatic transmission, power steering and
power brakes.
B. ADDITIONAL EQUIPMENT - SINGLE DISABILITIES
LOSS OF LEFT FOOT (INCLUDING LOSS OF USE)
LOSS OF RIGHT FOOT (INCLUDING LOSS OF USE)
1. Hand-operated dimmer switch
1. Left foot-operated gas pedal.
2. Hand-operated parking brake
2. Hand-operated dimmer switch.
3. If standard transmission selected, bar welded to clutch
3. Hand-operated parking brake.
pedal to prevent foot slipping down or off to side.
4. Extension on brake pedal from left foot operation if
LOSS OF LEFT HAND (INCLUDING LOSS OF USE)
not part of car.
1. Steering wheel knob or ring.
5. If standard transmission selected, bar welded to clutch
pedal so both clutch and brake pedals may be operated
2. Right-hand operated direction signals.
with the left foot.
3. Right-hand or foot-operated parking brake.
LOSS OF RIGHT HAND (INCLUDING LOSS OF USE)
4. Relocation of control switched, as needed.
1. Steering wheel knob or ring.
2. Left hand-or foot-operated parking brake.
3. Relocation of control switches, as needed.
4. Left hand gear shift lever.
C. ADDITIONAL EQUIPMENT - MULTIPLE DISABILITIES
LOSS OF BOTH FEET (INCLUDING LOSS OF USE)
LOSS OF BOTH HANDS, TRIPLE OR QUADRUPLE
EXTREMITY LOSS (INCLUDING LOSS OF USE)
1. Hand-operated brake and gas pedal in combination.
Any combination of hand/foot control which does not
2. Hand-operated parking brake.
involve steering, and relocation of control switches or
levers as required.
3. Hand-operated dimmer switch.
4. Steering wheel knob or ring.
5. Two-way power seat.
PAGE 4
VA FORM 21-4502, FEB 2015

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