Form VR-04 at a glance
What it is: Form VR-04 is the Application for VR Services.
Who signs: Signature of applicant, parent, or legal guardian*: I hereby apply for rehabilitation services. *If you are under the age of 18, or have a legal guardian, they will need to sign the application on your behalf.
A filled-in Form VR-04 example: Pat Sample applies for VR services
How to fill out Form VR-04, box by box
NAME and GENDER
Enter your NAME as Last, First and Middle Initial, and mark your GENDER.
GENDER: Male, Female and Gender X/Does not wish to self-identify.
If you have been known by another name and SOCIAL SECURITY NUMBER
If you have been known by another name, enter it here. Enter your SOCIAL SECURITY NUMBER.
Enter Last, First and Middle Initial.
HOME ADDRESS
Under HOME ADDRESS, enter Street, Apartment Number, City, State, Zip Code and County.
MAILING ADDRESS
If your MAILING ADDRESS is different than your home address, complete the mailing address information.
Under MAILING ADDRESS, enter Street, Apartment Number, City, State, Zip Code and County.
Select VR Office
Select the VR Office you would like to receive services from.
PHONE NUMBER(S) and Email
Enter the PHONE NUMBER(S) where you can be reached or leave a message.
For each phone number: Area code, Phone Number, Best time to call and Phone Type. Email:
Race/Ethnicity and DATE OF BIRTH
Race/Ethnicity-Choose ALL that apply. If left blank ACCES will complete. If Hispanic or Latino is checked, please check additional box. American Indian or Alaska Native, Hispanic or Latino, Asian (includes Indian Subcontinent), Native Hawaiian or Other Pacific Islander, Black or African American, White. DATE OF BIRTH: Month, Day, Year.
Your disability, who referred you and MARITAL STATUS
What is your disability?
Who referred you? MARITAL STATUS: Married, Widowed, Divorced, Separated or Never Married.
Working with any other agency, work limits and services
Please answer the following questions to the best of your ability at this time. If you're unable to, they will be reviewed when your application is processed.
Yes or No: Are you currently working with any other governmental or not-for-profit agency?
Describe how your disability limits your ability to work.
What services are you seeking from ACCES-VR?
Please provide any additional supporting documentation.
Injury, veteran, assistive devices and United States citizen
Yes or No: Are you disabled because of a work-related injury?
Yes or No: Are you a veteran?
Yes or No: Do you use any assistive devices or aids?
Yes or No: Are you a citizen of the United States? Yes or No: Do you have a NYS driver's license?
Driver's licenses, motor vehicle and transportation
Yes or No: Do you have a driver's license from a state other than New York?
Yes or No: Do you have access to a motor vehicle?
Yes or No: Do you use public transportation?
Yes or No: Are you able to leave your home?
Benefits you now receive
Check the benefits you now receive: SSI, SSDI, Workers Compensation or Other, specify.
Doctor or clinic about your disability
Yes or No: Do you regularly see a doctor or clinic about your disability? If yes, indicate date of last visit and provide the name and address of doctor(s) and clinic(s): (1) and (2).
Education
List the highest grade you have successfully completed and check the applicable box(es).
Yes or No for GED or High School Equivalency Diploma, and check College, Graduate School or Doctorate.
Yes or No for Special Education and for Do you now attend high school? Indicate college degree(s) earned.
Under Last School Attended, enter the Name of School and the Address.
Other people in your household
List other people in your household: Full Name, Age and Their Relationship to You.
People ACCES-VR can contact
List the people ACCES-VR can contact if ACCES-VR is unable to reach you using the information on page 1: Name, Address and Phone.
Your work history
List your work history (include attachments for additional Jobs, if necessary): Employer Name and Address, Dates Employed From To, Weekly Earnings, and Job Title and Duties, and Reason for Leaving.
Signature and date
SIGN and enter the Date.
More rules for Form VR-04
A description of the review process and form can be obtained from any ACCES-VR District Office.
All information will be kept confidential and is subject to verification.
Sources
[1] Form VR-04 (9/23), Application for VR Services, New York State Education Department, ACCES-VR (the Official source link on this page).
