Va Form 1107 PDF Details

Understanding the VA 1107 form is crucial for individuals requiring repairs or accessories for devices supplied by the Department of Veterans Affairs. This comprehensive form serves as a bridge between veterans or device users and the necessary maintenance or enhancement of their devices, ensuring they continue to serve their purpose effectively. It details a straightforward process, beginning with filling out personal information and device specifics, followed by indicating the type of request, whether for repairs or accessories. The form emphasizes the importance of wrapping the device securely and provides a specific mailing address to the Denver Distribution Center for processing. The VA 1107 form delineates clear instructions on how to clearly describe defects or specify needed accessories, including cords, tubing, or wax guards, highlighting the intention to make the procedure as effortless as possible for the requester. By completing this form, veterans can efficiently communicate their needs to the Department of Veterans Affairs, ensuring their devices are promptly attended to and remain functional for their daily use.

QuestionAnswer
Form NameVa Form 1107
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names1107, va form 1107, va form 1107 fillable, rubing

Form Preview Example

REQUEST FOR REPAIRS, AND/OR ACCESSORIES

INSTRUCTIONS

WHEN REPAIRS ARE NEEDED

1.Please complete items 1 through 8 and check appropriate box in Section I - Repairs that best explains your reason for returning the device for repairs.

2.Wrap device (including transmitter, receiver, cords, tubing, etc.) in a protective foam blanket or some other protective product and place in a postal pouch with this form and mail too: Department of Veterans Affairs, Denver Distribution Center, P.O. Box 25166, Denver, CO 80225-0166. DO NOT SEND earmold, presentatin case, eyeglass fronts, etc.

WHEN ACCESSORIES ARE NEEDED FOR THIS DEVICE

1.Please complete items 1 through 8 and Section II - Accessories. Indicate item(s) needed, cords, rubing, wax guards, earhooks, etc. Please indicate length when ordering cords or straight tubing.

2.Place defective items (cords or tubing if necessary) in a postal pouch along with this form and mail too: Department of Veterans Affairs, Denver Distribution Center, P.O. Box 25166, Denver, CO 80225-0166.

1. LAST NAME, FIRST NAME, MIDDLE INITIAL

2.DATE OF BIRTH (MM/DD/YYYY)

3.LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NO.

4.DATE MAILED (MM/DD/YYYY)

5. HOME MAILING ADDRESS

DEVICE INFORMATION

6. MAKE

7. MODEL

 

 

8. SERIAL NUMBER(S)

SECTION I - REPAIRS

1.DESCRIPTION OF DEFECTS (Check appropriate box(es))

 

DEAD

FADES

INTERMITTENT

MOISTURE DAMAGE

TELE COIL DEAD/WEAK

 

NOISY

WEAK

DISTORTED

EXCESSIVE BATTERY DRAIN

FEEDBACK

 

SECTION II - ACCESSORIES

1.ITEM(S) NEEDED

2.REMARKS

VA FORM

(ELECTRONIC VERSION)

JUN 1998 (RS) 1107

 

How to Edit Va Form 1107 Online for Free

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