Fillable Application For Annual Clothing Allowance (Fillable) (Page 2 of 2) in pdf

Application For Annual Clothing Allowance (Fillable) Page 2

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9. Month and

11. List all impacted

7. Type of Appliance or Name of Skin

8. List of Service-Connected

Year Appliance

10. Name and location of VA facility that issued appliance or

FOR VA USE

location(s)

Medication (Artificial leg, metal brace,

Disability/Disabilities Requiring Use

or Skin

skin medication (if not a VA facility include facility's phone

ONLY

(Chest, Back, Buttock, Left or

wheelchair, etc.)

of Appliance(s) or Skin Medication(s)

Medication was

number)

APPROVED?

Right Leg, Left or Right Arm)

issued

(MM/YYYY)

Example A

Yes

Example B

Yes

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.

FOR VA USE ONLY

# ELIGIBLE

# NOT ELIGIBLE

# UPPER Extremity (2 maximum)

# LOWER Extremity (2 maximum)

12. AMOUNT OF CLOTHING ALLOWANCES

13. EXAMINATION/EVALUATION DATE (If applicable)

14. NOTES:

15. GENERATED BY:

DATE

16. AUTHORIZED BY: