Veteran/beneficiary Claim For Reimbursement Of Travel Expenses Page 3

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OMB Number: 2900-0798

Estimated Burden: 15 minutes

VETERAN/BENEFICIARY CLAIM FOR

REIMBURSEMENT OF TRAVEL EXPENSES

Section A. Traveler's Information

1.a Name of Person Claiming Travel Reimbursement (Last, First, Middle)

1.b Claimant's SSN

1.c Claimant's Date of Birth (mm/dd/yyyy)

2.a Claimant's status: (check one) Complete 3.a, 3.b, 3.c and 3.d if Caregiver, Attendant or Donor is checked.

Caregiver

Attendant

Donor

Veteran

Other

(National Caregiver Program)

(Medically authorized by VA)

(VA Transplant Care)

3.a Name of Veteran (Last, First, Middle)

3.b Veteran's SSN

3.c Veteran's Date of Birth (mm/dd/yyyy)

Section B. Trip Information

1.a I am claiming travel reimbursement from address:

(Street, City, State, Zip)

1.b Date Trip Began

1.c Travel by:

(mm/dd/yyyy)

(e.g., car, train, bus,

taxi)

2.a I am claiming return travel reimbursement to the address in B.1.a above

2.b Date Trip Ended

2.c Travel by:

(mm/dd/yyyy)

(e.g., car, train, bus,

YES

NO (if no, provide the Street, City, State, Zip below)

taxi)

YES

3. I am claiming reimbursement of expenses other than mileage, such as tolls, parking, lodging, meals.

(If yes, itemize expenses below and provide a receipt for each expense claimed. Use reverse if additional space is required)

4. Treating Facility Name (VA or Non-VA location)

5. Treating Facility Address (Optional)

Section C. Statements and Certifications

Penalty Statement: There are severe criminal and civil penalties including fine or imprisonment, or both, for knowingly submitting a false, fictitious, or fraudulent

claim

Certification: I have incurred a cost in relation to the travel claimed. I have not obtained transportation at Government expense, through the use of Government

owned conveyance, or Government purchased tickets/tokens, or received other transportation resources at no-cost to me. I am the only person claiming for the

travel listed. I have not previously received payment for the transportation claimed. I certify that the above information is correct.

Signature of Claimant

Date (mm/dd/yyyy)

VA FORM

10-3542

NOV 2013