Va Form 21 4502 – Fill Out and Use This PDF

Va Form 21 4502 is a VA form requesting the veteran to provide information about enrollment in elementary or secondary school.

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Va Form 21 4502 PDF Details

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Question	Answer
Form Name	Va Form 21 4502
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	va form 21 4502 fillable, va automobile allowance, va form 21 4502 pdf, va car grant form

12

Form Preview Example

OMB Control No. 2900-0067

Respondent Burden: 15 Minutes

Expiration Date: 07/31/2024

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR AUTOMOBILE OR OTHER CONVEYANCE

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

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent on page 2. Use this form to apply for automobile or other conveyance and adaptive equipment allowance (38 U.S.C. Chapter 39). For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are available at www.va.gov/vaforms. After completing the form, mail to: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.

SECTION I - VETERAN/SERVICEMEMBER'S IDENTIFICATION INFORMATION

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, and completely fill in each applicable circle to help expedite processing of the form.

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

2. SOCIAL SECURITY NUMBER		3. VA FILE NUMBER (If applicable)	4. DATE OF BIRTH
			Month	Day	Year

			7. E-MAIL ADDRESS	I agree to receive electronic correspondence

5. VETERAN'S SERVICE NUMBER (If applicable) 6. TELEPHONE NUMBER (Include Area Code)
				from VA in regards to my claim.

Enter International

Phone Number (If applicable)

NOTE: A servicemember planning early release should give both present military address and planned address following release from active duty, in Items 8A and 8B.

8A. CURRENT ADDRESS (No. and Street or rural route, City or P.O., State and Zip Code) No. &

Street Apt./Unit Number

State/Province

City

Country

ZIP Code/Postal Code

8B. SERVICEMEMBER'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY (No. and Street or rural route, City or P.O., State and Zip Code) No. &

Street Apt./Unit Number

State/Province

City

Country

ZIP Code/Postal Code

SECTION II - APPLICATION INFORMATION

9. BRANCH OF SERVICE

COAST

SPACE

OTHER

10. ARE YOU ON ACTIVE DUTY?

ARMY

NAVY

MARINE CORPS

AIR FORCE

YES

NO

GUARD

FORCE

(Specify)

11A. PLACE OF ENTRY INTO ACTIVE DUTY

11B. DATE OF ENTRY

Month

Day

Year

11C. PLACE OF RELEASE FROM ACTIVE DUTY (If applicable)

11D. DATE OF RELEASE

Month

Day

Year

12A. HAVE YOU APPLIED FOR VA DISABILITY

12B. DATE YOU APPLIED

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

COMPENSATION? (If "Yes," give place)

YES

NO

Month

Day

Year

14. TYPE OF CONVEYANCE APPLIED FOR (Check one)

	AUTOMOBILE	STATION WAGON	VAN	TRUCK	OTHER
					(Specify)

15. HAVE YOU PREVIOUSLY APPLIED FOR AN AUTOMOBILE OR OTHER CONVEYANCE? (This is a once-per-lifetime grant)

	Month	Day	Year			Place
YES	NO (If "Yes,"give date and place)

I hereby apply for the conveyance checked in Item 14 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.

16. SIGNATURE OF VETERAN OR SERVICEMEMBER (REQUIRED)

17. DATE SIGNED

Month

Day

Year

JUL 2021

21-4502

VA FORM

SUPERSEDES VA FORM 21-4502, MAR 2018.

PAGE 1

VETERAN/SERVICEMEMBER'S SOCIAL SECURITY NO.

SECTION III - CERTIFICATE OF ELIGIBILITY (To be completed by VA)

QUALIFYING DISABILITIES (Check appropriate box(es))

18A. LOSS OF FOOT			18B. LOSS OF HAND			18C. PERMANENT LOSS OF USE OF FOOT			18D. PERMANENT LOSS OF USE OF HAND
RIGHT	LEFT	BOTH	RIGHT	LEFT	BOTH	RIGHT	LEFT	BOTH	RIGHT	LEFT	BOTH
19. PERMANENT IMPAIRMENT OF VISION						20. SEVERE BURN INJURY			21. AMYOTROPHIC LATERAL SCLEROSIS
CENTRAL VISUAL ACUITY 20/200 OR LESS IN THE BETTER EYE									(ALS)
CENTRAL VISUAL ACUITY 20/200 OR LESS IN THE BETTER EYE
WITH CORRECTIVE GLASSES						YES	NO		YES	NO
CONTRACTION OF THE PERIPHERAL FIELD OF VISION TO 20						YES	NO		YES	NO
CONTRACTION OF THE PERIPHERAL FIELD OF VISION TO 20
DEGREES OR LESS IN THE BETTER EYE

22.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 14, 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 does not 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.

23. NAME AND LOCATION OF VA OFFICE

24A. SIGNATURE OF CERTIFYING OFFICIAL

24B. DATE SIGNED (MM/DD/YYYY)

TITLE OF CERTIFYING OFFICIAL

SECTION IV - RECEIPT FOR AUTOMOBILE OR OTHER CONVEYANCE AND ADAPTIVE EQUIPMENT (To be completed by veteran or servicemember)

25. MAKE AND MODEL

26. YEAR

27. VEHICLE IDENTIFICATION NO. (VIN)

28. TOTAL PURCHASE PRICE

.

29. DATE OF SALE (MM/DD/YYYY)

$

,

30A. I WILL OPERATE THIS VEHICLE

30B. I HAVE A VALID STATE DRIVER'S LICENSE OR LEARNER'S PERMIT

YES

NO

YES

NO

31. NAME OF SELLER

32. ADDRESS OF SELLER

I hereby acknowledge receipt of the automobile or other conveyance with the adaptive equipment specified on attached invoice.

33A. SIGNATURE OF VETERAN OR SERVICEMEMBER (REQUIRED)

33B. DATE OF RECEIPT (MM/DD/YYYY)

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.

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.

VA FORM 21-4502, JUL 2021

PAGE 2

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.custhelp.com/

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.

VA FORM 21-4502, JUL 2021

PAGE 3

ADAPTIVE EQUIPMENT FOR AUTOMOBILES AND SIMILAR VEHICLES

IMPORTANT

Adaptive equipment for the operation of the vehicle cannot be provided if the veteran or servicemember 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

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.

B. ADDITIONAL EQUIPMENT - SINGLE DISABILITIES

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.

C. ADDITIONAL EQUIPMENT - MULTIPLE DISABILITIES

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.

VA FORM 21-4502, JUL 2021

PAGE 4

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For you to fill in the form, enter the details the application will ask you to for each of the next parts:

va form 21 4502 pdf fields to complete

Inside the box BRANCH OF SERVICE, SECTION II APPLICATION INFORMATION, ARMY, NAVY, MARINE CORPS, AIR FORCE, COAST GUARD, SPACE FORCE, OTHER Specify, A PLACE OF ENTRY INTO ACTIVE DUTY, C PLACE OF RELEASE FROM ACTIVE, ARE YOU ON ACTIVE DUTY, YES, B DATE OF ENTRY, and Month enter the information that the platform requires you to do.

Filling out va form 21 4502 pdf stage 2

Describe the significant information in the VETERANSERVICEMEMBERS SOCIAL, SECTION III CERTIFICATE OF, QUALIFYING DISABILITIES Check, A LOSS OF FOOT, B LOSS OF HAND, C PERMANENT LOSS OF USE OF FOOT D, RIGHT, LEFT, BOTH, RIGHT, LEFT, BOTH, RIGHT, LEFT, and BOTH segment.

Completing va form 21 4502 pdf part 3

Inside of field SECTION IV RECEIPT FOR AUTOMOBILE, MAKE AND MODEL, YEAR, VEHICLE IDENTIFICATION NO VIN, TOTAL PURCHASE PRICE, DATE OF SALE MMDDYYYY, A I WILL OPERATE THIS VEHICLE, B I HAVE A VALID STATE DRIVERS, YES, NAME OF SELLER, YES, ADDRESS OF SELLER, I hereby acknowledge receipt of, A SIGNATURE OF VETERAN OR, and B DATE OF RECEIPT MMDDYYYY, state the rights and responsibilities.

part 4 to finishing va form 21 4502 pdf

Finalize by taking a look at the following areas and completing them accordingly: RESPONDENT BURDEN We need this, VA FORM JUL, and PAGE.

part 5 to filling out va form 21 4502 pdf

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