Fillable Va Form Fl 10-426 - Temporary Loan Follow-Up Letter printable pdf download

Va Form Fl 10-426 - Temporary Loan Follow-Up Letter

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DEPARTMENT OF VETERANS AFFAIRS

In Reply Refer To:

Dear

Our records indicate you have been furnished the following listed item(s) on loan:

If you are still using the item(s), (it) (they) may be retained for your use for as long as you will need them. On the

other hand, if you no longer use or need the item(s), (it) (they) must be returned for possible use by another

veteran.

Please answer the questions below and return the letter to us. If you have any additional remarks or comments, use

the back of this letter.

Thank you for your cooperation.

Sincerely,

OMB NO. 2900-0188

Estimated Burden: I minute

Expiration Date: 11/30/2007

This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you

arenot required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all providers who must

complete this form will average 1 minute. This includes the time to read instructions, gather the necessary facts and fill out the form. This collection of information is

intended to identify prosthetic items which can be used by another individual and items that have exceeded their usefulness. Response to this letter is voluntary

andfailure to respond will have no adverse effect on benefits to which you might otherwise be entitled.

1. HAVE/HAS THE ITEM(S) BEEN SATISFACTORY?

2. HOW OFTEN HAVE YOU USED IT/THEM?

NO (if ' ' No' ' , explain on reverse)

NEVER

2 OR 3 TIM ES

AS OFTEN AS NEEDED

YES

3. WHAT IS THE PRESENT CONDITION OF THE ITEM(S)?

4. DO YOU STILL NEED THE ITEM(S)?

NOT

GOOD