Application For Automobile Or Other Conveyance And Adaptive Equipment(Va Form 21-4502)

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OMB Control No. 2900-0067

Respondent Burden: 15 Minutes

Expiration Date: 01/31/2018

APPLICATION FOR AUTOMOBILE OR OTHER CONVEYANCE

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

1A.VA FILE NUMBER

1B. VETERAN'S SOCIAL SECURITY NUMBER

NOTE: Please read the "Information and Instructions" on Page 3 before you fill out this form.

(To be completed by veteran or serviceperson)

SECTION I - APPLICATION

NOTE: A serviceperson planning early release should give both present military address and planned address following release from active duty, in Items 3A and 3B.

2. FIRST NAME - MIDDLE INITIAL - LAST NAME

(No. and Street or rural route, City or P.O., State and Zip Code)

3A. CURRENT ADDRESS

Number and Street

or Rural Route, P.O.

Box

Apt./Unit Number

City, State, ZIP Code

Country

(No. and Street or rural route, City or P.O., State and Zip Code)

3B. SERVICEPERSON'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY

Number and Street

or Rural Route, P.O.

Box

Apt./Unit Number

City, State, ZIP Code

Country

4. BRANCH OF SERVICE

5. ARE YOU ON ACTIVE DUTY?

AIR

MARINE

COAST

OTHER

ARMY

NAVY

YES

(Specify)

FORCE

CORPS

GUARD

6A. PLACE OF ENTRY INTO ACTIVE DUTY

6B. DATE OF ENTRY

Month

Day

Year

(If applicable)

6C. PLACE OF RELEASE FROM ACTIVE DUTY

6D. DATE OF RELEASE

Month

Day

Year

(If known)

7B. DATE YOU APPLIED

8. LOCATION OF VA OFFICE THAT HAS YOUR FILE

7A. HAVE YOU APPLIED FOR VA DISABILITY

(If "Yes,"give place)

COMPENSATION?

Month

Day

Year

YES

(Check one)

9. TYPE OF CONVEYANCE APPLIED FOR

STATION

OTHER

AUTOMOBILE

VAN

TRUCK

WAGON

(Specify)

(This is a once-per-lifetime grant)

10. HAVE YOU PREVIOUSLY APPLIED FOR AN AUTOMOBILE OR OTHER CONVEYANCE?

(If "Yes,"give date and place)

YES

Month

Day

Year

I hereby apply for the conveyance checked in Item 9 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.

(Include Area Code)

13. TELEPHONE NUMBERS

11. SIGNATURE OF VETERAN OR SERVICEPERSON

12. DATE SIGNED

Month

Day

Year

A. DAYTIME

B. EVENING

(

)

(