Application For Automobile Or Other Conveyance And Adaptive Equipment(Va Form 21-4502) Page 3

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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.va.gov

A. What are automobile and adaptive equipment benefits and how does VA

C. When should VA Form 21-4502 be submitted?

decide what I will or will not receive?

There is no time limit for filing a claim; however, the claim must be authorized by

VA before you purchase the automobile or conveyance.

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

D. Instructions to veteran or serviceperson

eligible. This payment is a once-per-lifetime grant, and the amount paid is limited

1. Complete all items of Section I in duplicate and submit both copies to VA. If

by law. Contact VA for the current rate.

you have previously applied for disability compensation, send the form to the VA

regional office where your claims folder is located. If you have not applied for

A veteran or serviceperson must possess one of the following disabilities as a

disability compensation or have not separated from military service, send the form

result of injury or disease incurred or aggravated during active military service:

to the nearest VA regional office.

• loss or permanent loss of use of one or both feet, or

2. VA will determine your eligibility and, if eligibility exists, VA will complete

Section II and return the form to you.

• loss or permanent loss of use of one or both hands, or

• permanent impairment of vision in both eyes with a

3. Purchase a vehicle. When you receive the vehicle and the adaptive equipment

• central visual acuity of 20/200 or less in the better eye with corrective

from the seller, complete Section III.

glasses, or

4. Give the original VA Form 21-4502 to the seller.

• 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

5. Submit any invoices for adaptive equipment and/or installation not included on

widest diameter of visual field has an angular distance no greater

the seller's invoice to the nearest VA health care facility. These invoices,

than 20 degrees in the better eye, or

identified with your full name and VA file number, must show the itemized net

• Severe burn injury: Deep partial thickness or full thickness burns resulting in

cost of any adaptive equipment and installation charges, any unpaid balance, and

scar formation that cause contractures and limit motion of one or more

the make, year and model of the vehicle to which the equipment is added.

extremities or the trunk and preclude effective operation of an automobile, or

• amyotrophic lateral sclerosis (ALS).

E. Instructions to seller

1. Make sure that Section II of VA Form 21-4502 is completed and signed by VA.

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

2. Deliver the vehicle, including VA-approved adaptive equipment provided and/

veteran or serviceperson.

or installed by the seller.

2. Adaptive equipment

3. Obtain the original copy of VA Form 21-4502 from the veteran or

A veteran or serviceperson who qualifies for the vehicle allowance also qualifies

serviceperson after he or she has completed Section III.

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

4. Submit the original copy of VA Form 21-4502 and itemized invoice to the VA

information about adaptive equipment. Important: VA will not pay for the

regional office shown in Section II, Attention: Financial Division, for payment.

purchase of add-on adaptive equipment (equipment furnished by someone other

The itemized invoice must include the following:

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

• The net cost of any approved adaptive equipment and installation charges. If

adaptive equipment benefit may be paid more than once, and it may be paid to

certain items of approved adaptive equipment (automatic transmission,

either the seller or the veteran or serviceperson.

power seats, etc.) are included in the purchase price, also submit a copy of

the window sticker.

3. Special drivers training for disabled veterans should contact the nearest VA

health care facility to request this training.

• A list of which adaptive equipment is standard on the vehicle or combined

with other items.

B. What conveyance may be purchased?

• The unpaid balance due on the vehicle which is to be paid by VA.

You may purchase a new or used automobile, truck, station wagon, or certain

other types of conveyance if approved 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 If desired, you can call 1-800-827-1000 to get

information on where to send comments or suggestions about this form.

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VA FORM 21-4502, FEB 2015