Veteran/beneficiary Claim For Reimbursement Of Travel Expenses

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VA SAN DIEGO HEALTHCARE SYSTEM
INSTRUCTIONS FOR COMPLETING MILEAGE REIMBURSEMENT REQUEST FORM
Please note: All previous forms used for requesting mileage reimbursement are now obsolete
and can no longer be accepted.
Section A
Box 1a: Veteran’s name
Box 1b: Last four of the Veteran’s Social Security Number only
Box 1c: Veteran’s date of birth
Box 2a: Please mark as appropriate
Box 3a: Veteran’s last name, first name, and middle initial
Box 3b: Last four digits of the Veteran’s social security number
Box 3c: Veteran’s date of birth
Section B
Box 1a: Please list the Veteran’s actual residential address; Please do not list a P;O; Box.
Box 1b: Date the Veteran left home to come to VA appointment.
Box 1c: Method of transportation used. Examples: car, bus, train, etc.
Box 2a: Please mark as appropriate
Box 2b: Date the Veteran returned home following the VA appointment
Box 2c: Please mark as appropriate
Box 3: Veterans may claim for expenses other than mileage such as lodging and meals only if
reimbursement for lodging and meals was pre-approved by the VA prior to commencing travel.
In such cases, Veterans must include receipts.
( CONTINUED ON OTHER SIDE )

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