Here is the information regarding the file you were looking for to complete. It will show you how much time it takes to finish va form 21 4502, what parts you will have to fill in and some other specific details.
Question | Answer |
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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, form 4502, va automobile grant, va auto allowance |
OMB Control No.
Respondent Burden: 15 Minutes
Expiration Date: 03/31/2021
APPLICATION FOR AUTOMOBILE OR OTHER CONVEYANCE
AND ADAPTIVE EQUIPMENT (UNDER 38 U.S.C.
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
SECTION I - VETERAN/SERVICEMEMBER IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly 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) |
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4.DATE OF BIRTH (MM/DD/YYYY)
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Year |
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5. VETERAN'S SERVICE NUMBER (If applicable)
6.TELEPHONE NUMBER (Include Area Code)
7.
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
City
State/Province
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
City
State/Province
Country
ZIP Code/Postal Code
SECTION II - APPLICATION INFORMATION
9. BRANCH OF SERVICE |
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10. ARE YOU ON ACTIVE DUTY? |
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ARMY |
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NAVY |
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AIR |
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MARINE |
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COAST |
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OTHER |
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YES |
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NO |
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FORCE |
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CORPS |
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GUARD |
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(Specify) |
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11A. PLACE OF ENTRY INTO ACTIVE DUTY |
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11B. DATE OF ENTRY |
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11C. PLACE OF RELEASE FROM ACTIVE DUTY (If applicable) |
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11D. DATE OF RELEASE |
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12A. HAVE YOU APPLIED FOR VA DISABILITY COMPENSATION? (If "Yes,"give place)
YES NO
12B. DATE YOU APPLIED
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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)
15. HAVE YOU PREVIOUSLY APPLIED FOR AN AUTOMOBILE OR OTHER CONVEYANCE? (This is a
YES |
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NO |
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Day |
Year |
Place |
(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
(Sign in ink)
17. DATE SIGNED
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Day |
Year |
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18.TELEPHONE NUMBERS (Include Area Code)
A. DAYTIME |
B. EVENING |
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VA FORM |
EXISTING STOCKS OF VA FORM |
PAGE 1 |
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MAR 2018 |
WHICH WILL BE USED. |
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VETERAN/SERVICEMEMBER'S SOCIAL SECURITY NO.
SECTION III - CERTIFICATE OF ELIGIBILITY (To be completed by VA)
QUALIFYING DISABILITIES (Check appropriate box(es))
19A. LOSS OF FOOT |
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19B. LOSS OF HAND |
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19C. PERMANENT LOSS OF USE OF FOOT |
19D. PERMANENT LOSS OF USE OF HAND |
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RIGHT |
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BOTH |
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BOTH |
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BOTH |
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LEFT |
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BOTH |
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20. PERMANENT IMPAIRMENT OF VISION |
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21. SEVERE BURN INJURY |
22. AMYOTROPHIC LATERAL SCLEROSIS |
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CENTRAL VISUAL ACUITY 20/200 OR LESS IN THE BETTER EYE |
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(ALS) |
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WITH CORRECTIVE GLASSES |
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YES |
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NO |
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YES |
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NO |
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CONTRACTION OF THE PERIPHERAL FIELD OF VISION TO 20 |
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DEGREES OR LESS IN THE BETTER EYE |
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23. Authorization for Allowance for Automobile or Other Conveyance: The
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 doesn't 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
I CERTIFY THAT the veteran has not previously received an allowance for automobile or other conveyance under 38 U.S.C.
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24. NAME AND LOCATION OF VA OFFICE |
25A. SIGNATURE OF CERTIFYING OFFICIAL |
25B. DATE SIGNED |
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TITLE OF CERTIFYING OFFICIAL |
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SECTION IV - RECEIPT FOR AUTOMOBILE OR OTHER CONVEYANCE AND ADAPTIVE EQUIPMENT (To be completed by veteran or servicemember)
26. MAKE AND MODEL |
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27. YEAR |
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28. VEHICLE IDENTIFICATION NO. (VIN) |
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29. TOTAL PURCHASE PRICE |
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30. DATE OF SALE |
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$ |
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31A. I WILL OPERATE THIS VEHICLE |
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31B. I HAVE A VALID STATE DRIVER'S LICENSE OR LEARNER'S PERMIT |
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YES |
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NO |
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YES |
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NO |
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32. NAME OF SELLER |
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33. ADDRESS OF SELLER |
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I hereby acknowledge receipt of the automobile or other conveyance with the adaptive equipment specified on attached invoice. |
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34A. SIGNATURE OF VETERAN OR SERVICEMEMBER (Sign in ink) |
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34B. DATE OF RECEIPT |
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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.
VA FORM |
PAGE 2 |
INFORMATION AND INSTRUCTIONS
If you have questions about this form, how to fill it out, or about benefits, call VA
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
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
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
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
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
2.Deliver the vehicle, including
3.Obtain the original copy of VA Form
4.Submit the original copy of VA Form
•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.
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
VA FORM |
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
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.
2.
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.
3.
4.Relocation of control switched, as needed.
LOSS OF RIGHT FOOT (INCLUDING LOSS OF USE)
1.Left
2.
3.
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
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.
2.
3.
4.Steering wheel knob or ring.
5.
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 |
PAGE 4 |