When repairs are needed, fill out completely all items in the top section and Section I on the reverse side of this form.
Carton: when repairs are needed, enclose the form in the carton along with the defective device.
Mailing: wrap the carton, attach the Denver Acquisition & Logistics Center postage-free label, and deposit in U.S. Postal Service mail.
Accessories: when accessories are needed for this device, fill out completely all items in the top section and Section II on the reverse side of this form.
Items needed: indicate item(s) needed, cords, tubing, wax guards, ear hooks, etc. Please indicate length when ordering cords or straight tubing.
| Question | Answer |
|---|---|
| Form Name | VA Form 1107 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 22 |
| Avg. time to fill out | 4 min |
| Edition | OCT 2006 |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | VA Form 1107, VA 1107, Form 1107, Request for Repairs, and/or Accessories |
| Official source | VA Form 1107 (Rev OCT 2006), Department of Veterans Affairs |
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