Va Form 21 4502 – Fill Out and Use

APPLICATION FOR AUTOMOBILE OR OTHER CONVEYANCE

AND ADAPTIVE EQUIPMENT (UNDER 38 U.S.C. 3901-3904)

IMPORTANT: Read the "Information and Instructions" on Page 3 before completing this form. Also, read the Privacy Act and Respondent Burden information below before completing the form.

VA DATE STAMP

DO NOT WRITE IN THIS SPACE

1. VETERAN/SERVICEMEMBER'S NAME (First, Middle Initial, Last)

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

5. VETERAN'S SERVICE NUMBER (If applicable)

6.TELEPHONE NUMBER (Include Area Code)

7. E-MAIL ADDRESS (Optional)

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

12A. HAVE YOU APPLIED FOR VA DISABILITY COMPENSATION? (If "Yes,"give place)

YES NO

12B. DATE YOU APPLIED

13. LOCATION OF VA OFFICE THAT HAS YOUR FILE (If known)

14. TYPE OF CONVEYANCE APPLIED FOR (Check one)

AUTOMOBILE STATION VAN WAGON

TRUCK

OTHER

(Specify)

16.SIGNATURE OF VETERAN OR SERVICEMEMBER

(Sign in ink)

17. DATE SIGNED

18.TELEPHONE NUMBERS (Include Area Code)

A. What are automobile and adaptive equipment benefits and how does VA decide what I will or will not receive?

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 eligible. This payment is a once-per-lifetime grant, and the amount paid is limited by law. Contact VA for the current rate.

A veteran or servicemember must possess one of the following disabilities as a result of injury or disease incurred or aggravated during active military service:

•loss or permanent loss of use of one or both feet, or

•loss or permanent loss of use of one or both hands, or

•permanent impairment of vision in both eyes with a

•central visual acuity of 20/200 or less in the better eye with corrective glasses, or

•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 widest diameter of visual field has an angular distance no greater than 20 degrees in the better eye, or

•Severe burn injury: Deep partial thickness or full thickness burns resulting in scar formation that cause contractures and limit motion of one or more extremities or the trunk and preclude effective operation of an automobile, or

•amyotrophic lateral sclerosis (ALS).

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 veteran or servicemember.

2. Adaptive equipment

A veteran or servicemember who qualifies for the vehicle allowance also qualifies 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 information about adaptive equipment. Important: VA will not pay for the purchase of add-on adaptive equipment (equipment furnished by someone other 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 adaptive equipment benefit may be paid more than once, and it may be paid to either the seller or the veteran or servicemember.

3.Special drivers training for disabled veterans should contact the nearest VA health care facility to request this training.

B. What conveyance may be purchased?

You may purchase a new or used automobile, truck, station wagon, or certain other types of conveyance if approved by VA.

C. When should VA Form 21-4502 be submitted?

There is no time limit for filing a claim; however, the claim must be authorized by VA before you purchase the automobile or conveyance.

D. Instructions to veteran or servicemember

1.Complete all items of Section I and II and submit to VA. Send the form to your nearest VA regional office.

2.VA will determine your eligibility and, if eligibility exists, VA will complete Section III and return the form to you.

3.Purchase a vehicle. When you receive the vehicle and the adaptive equipment from the seller, complete Section IV.

4.Give the original VA Form 21-4502 to the seller.

5.Submit any invoices for adaptive equipment and/or installation not included on the seller's invoice to the nearest VA health care facility. These invoices, identified with your full name and VA file number, must show the itemized net cost of any adaptive equipment and installation charges, any unpaid balance, and the make, year and model of the vehicle to which the equipment is added.

E. Instructions to seller

1.Make sure that Section III of VA Form 21-4502 is completed and signed by VA.

2.Deliver the vehicle, including VA-approved adaptive equipment provided and/ or installed by the seller.

3.Obtain the original copy of VA Form 21-4502 from the veteran or servicemember after he or she has completed Section IV.

4.Submit the original copy of VA Form 21-4502 and itemized invoice to the VA regional office shown in Section III, Attention: Financial Division, for payment. The itemized invoice must include the following:

•The net cost of any approved adaptive equipment and installation charges. If certain items of approved adaptive equipment (automatic transmission, power seats, etc.) are included in the purchase price, also submit a copy of the window sticker.

•A list of which adaptive equipment is standard on the vehicle or combined with other items.

•The unpaid balance due on the vehicle which is to be paid 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.

DISABILITY

Loss of a foot (including loss of use)...............................

Loss of both feet (including loss of use)..........................

Loss of a hand (including loss of use).............................

Loss of a hand and a foot (including loss of use)............

ADAPTIVE EQUIPMENT

Basic automatic transmission and power brakes

Basic automatic transmission, power steering and power brakes.

Basic automatic transmission and power steering.

Basic automatic transmission, power steering and power brakes.

LOSS OF LEFT FOOT (INCLUDING LOSS OF USE)

1.Hand-operated dimmer switch

2.Hand-operated parking brake

3.If standard transmission selected, bar welded to clutch pedal to prevent foot slipping down or off to side.

LOSS OF LEFT HAND (INCLUDING LOSS OF USE)

1.Steering wheel knob or ring.

2.Right-hand operated direction signals.

3.Right-hand or foot-operated parking brake.

4.Relocation of control switched, as needed.

LOSS OF RIGHT FOOT (INCLUDING LOSS OF USE)

1.Left foot-operated gas pedal.

2.Hand-operated dimmer switch.

3.Hand-operated parking brake.

4.Extension on brake pedal from left foot operation if not part of car.

5.If standard transmission selected, bar welded to clutch pedal so both clutch and brake pedals may be operated with the left foot.

LOSS OF RIGHT HAND (INCLUDING LOSS OF USE)

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.

LOSS OF BOTH FEET (INCLUDING LOSS OF USE)

1.Hand-operated brake and gas pedal in combination.

2.Hand-operated parking brake.

3.Hand-operated dimmer switch.

4.Steering wheel knob or ring.

5.Two-way power seat.

LOSS OF BOTH HANDS, TRIPLE OR QUADRUPLE EXTREMITY LOSS (INCLUDING LOSS OF USE)

Any combination of hand/foot control which does not involve steering, and relocation of control switches or levers as required.