Form 21-4502 at a glance
What it is: Form 21-4502 is the Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904).
Where and when to file: After completing the form, mail it to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
A veteran or service member 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).
What to bring and attach to Form 21-4502
VA recommends that you consult with a VA healthcare provider prior to selecting a vehicle or other conveyance to ensure your adaptive equipment is compatible with a specific vehicle make/model.
A filled-in Form 21-4502 example: a veteran applies for an automobile
How to fill out Form 21-4502, box by box
Veteran/Service Member's Name, Social Security Number, Date of Birth, Telephone Number and E-mail Address
Enter the Veteran/Service Member's Name (First, Middle Initial, Last) in Box 1.
Enter the Social Security Number in Box 2, the VA File Number (If applicable) in Box 3 and the Date of Birth (MM/DD/YYYY) in Box 4.
Enter the Veteran's Service Number (If applicable) in Box 5 and the Telephone Number (Include Area Code) in Box 6; Enter International Phone Number (If applicable).
Enter the E-mail Address in Box 7, and check the box: I agree to receive electronic correspondence from VA in regards to my claim.
Boxes 8A and 8B, Current Address and Service Member's Planned Address Following Release From Active Duty
Enter the Current Address in Box 8A and the Service Member's Planned Address Following Release From Active Duty in Box 8B (No. and Street or rural route, City or P.O., State and Zip Code).
A service member planning early release should give both present military address and planned address following release from active duty, in Items 8A and 8B.
Boxes 9 and 10, Branch of Service and Are You on Active Duty?
Check one in Box 9, Branch of Service: Army, Navy, Marine Corps, Air Force, Coast Guard, Space Force, NOAA or USPHS; check Yes or No in Box 10, Are You on Active Duty?
Box 11, Entry Into and Release From Active Duty
Enter the Place of Entry Into Active Duty in Box 11A and the Date of Entry (MM/DD/YYYY) in Box 11B; enter the Place of Release From Active Duty (If applicable) in Box 11C and the Date of Release (MM/DD/YYYY) in Box 11D.
Boxes 12A, 12B and 13, Disability Compensation and VA Office
Check Yes or No for Box 12A, Have You Applied for VA Disability Compensation? (If "Yes," specify name of place); enter the Date You Applied (MM/DD/YYYY) in Box 12B and the Location of VA Office That Has Your File (If known) in Box 13.
Box 14, Type of Conveyance Applied For
Check one in Box 14, Type of Conveyance Applied For: Automobile, Station Wagon, Van, Truck or Other (Specify).
You may purchase a new or used automobile, or other conveyance, if approved by VA.
Box 15, Have You Previously Applied for an Automobile or Other Conveyance?
Check Yes or No for Box 15, Have You Previously Applied for an Automobile or Other Conveyance? (If "Yes," give date (mm/dd/yyyy) and place).
Items 16 and 17, Signature of Veteran or Service Member and Date Signed
Sign in Box 16, Signature of Veteran or Service Member (REQUIRED), and enter the Date Signed (MM/DD/YYYY) in Box 17.
You apply for the conveyance checked in Item 14 above and the equipment required because of your disability. You agree that before operating the vehicle you shall hereafter apply to the proper authority for the necessary license to operate it. If you are unable to qualify for a license, you certify that a person licensed to operate a similar vehicle in the state of your residence will operate the vehicle for you. You further certify that VA has not previously paid an automobile grant on your behalf or that either (1) the automobile previously purchased with assistance was destroyed as a result of a natural or other disaster, or (2) it has been 30 or more years since your most recent automobile grant. You must contact your local Veterans Health Administration (VHA) Prosthetic and Sensory Aids Service prior to obtaining any (new or used) adaptive equipment, and VA may deny claims for payment or reimbursements if eligibility has not been established or has been terminated.
Veteran/Service Member's Social Security No. on page 2
Enter the Veteran/Service Member's Social Security No.
Section III, Certificate of Eligibility (To be completed by VA)
VA will determine your eligibility and, if eligibility exists, VA will complete Section III and return the form to you.
Section III, Certificate of Eligibility (To be completed by VA), lists the Qualifying Disabilities (Check appropriate box(es)).
Section IV, Receipt for Automobile or Other Conveyance and Adaptive Equipment (To be completed by veteran or service member)
When you receive the vehicle and the adaptive equipment from the seller, complete Section IV.
Enter the Make and Model of the Automobile or Other Conveyance in Box 25, the Year (YYYY) in Box 26, the Vehicle Identification No. (VIN) in Box 27, the Total Purchase Price in Box 28 and the Date of Sale (MM/DD/YYYY) in Box 29.
Check Yes or No for Box 30A, I Will Operate This Vehicle, and for Box 30B, I Have a Valid State Driver's License or Learner's Permit.
Enter the Name of Seller in Box 31 and the Address of Seller in Box 32; sign in Box 33A, Signature of Veteran or Service Member (REQUIRED), and enter the Date of Receipt (MM/DD/YYYY) in Box 33B.
More rules for Form 21-4502
Give the original VA Form 21-4502 to the seller.
VA is required by law to pay the benefit to the seller of the vehicle. Payment cannot be made to the veteran or service member.
The amount paid is limited by law.
If your situation is different
If this is an additional automobile
If this is an additional automobile (the automobile previously purchased with assistance was destroyed as a result of a natural or other disaster, or 30 or more years since the most recent automobile grant), the veteran must contact their local VHA Prosthetic and Sensory Aids Service prior to obtaining any (new or used) adaptive equipment.
Effective January 5, 2023, claimants may receive an additional vehicle or conveyance if more than 30 years have elapsed since the eligible person most recently received an automobile or other conveyance.
Before you go
Do not purchase a vehicle until authorized by VA.
Common questions about Form 21-4502
What is VA Form 21-4502 used for?
Form 21-4502 is the Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904). Before completing this form, read the Privacy Act and Respondent Burden information 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 VA at https://ask.va.gov/, or call VA toll-free at 1-800-827-1000 (TTY: 711). VA forms are available at www.va.gov/vaforms.
Is there a deadline?
There is no time limit for filing a claim; however, the claim must be authorized by VA before you purchase the automobile or conveyance.
Where do I file it?
After completing the form, mail it to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
Is there a 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.
Sources
[1] VA Form 21-4502 (AUG 2024, supersedes JUL 2021), Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904), U.S. Department of Veterans Affairs (the Official source link on this page).
