10-2520 Prosthetic Service Card Invoice

OMB Number: 2900-0188
Estimated Burden: 4 minutes
VENDOR'S INVOICE NUMBER

PROSTHETIC SERVICE CARD INVOICE

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 are not
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 4 minutes. This includes the time to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to provide a
means of billing for repairs authorized by VA Form 10-2501. Although you must submit a bill to receive reimbursement, return of this form is voluntary. Failure to
respond will have no adverse effect on benefits to which you might otherwise be entitled.
VETERANS AFFAIRS

VETERAN'S NAME (Last, first, middle initial) (mandatory)

NAME AND ADDRESS OF FIRM OR DEALER

VETERAN'S ADDRESS

TO

CLAIM NUMBER

CSOCIAL SECURITY NUMBER
(This is a mandatory field.)

FROM

REPAIR DATA
INSTRUCTIONS - Itemize separately actual amount and charges for material and parts used in rendering repairs, GIVING COMPLETE
DESCRIPTION (DIMENSIONS, ETC.) OF MATERIAL USED AND/OR SPECIFIC ITEM REPAIRED. Labor charges will not be included in cost
of material or parts, and are to be listed separately. Indicate in the spaces provided hereon the name, type, and age of the appliance repaired.

NOTE: Payment will be deferred until these instructions are followed.
DATE

REPAIR DESCRIPTION

CHARGES

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

HYDRAULIC UNIT DESCRIPTION

REPLACEMENT HYDRAULIC UNIT SERIAL NUMBER

DATE INSTALLED (mm/dd/yyyy)

%

DAYS

TERMS: NET
NAME OF APPLIANCE MANUFACTURER
TYPE OF APPLIANCE

MALFUNCTIONING HYDRAULIC UNIT SERIAL NUMBER

DATE DELIVERED

DAYS

TOTAL
CHARGES

$

WARNING - Any abuse of this system by the vendor through excessive charges for
repairs or by the veteran in aiding or abetting such irregular activities may result in
discontinuation of the program and invocation of criminal statutes for frauds
against the Government.

CERTIFICATION OF VETERAN
I certify that this invoice has been completed to show total
charges; that charges seem proper for work done; that these
repairs were necessary and satisfactory

SIGNATURE OF VETERAN

ADMINISTRATIVE CERTIFICATION

VA FORM 10-2501 IS OF RECORD IN THIS CASE. PAYMENT AS
CLAIMED IS RECOMMENDED, WITH THE FOLLOWING EXCEPTIONS:

None

DATE (mm/dd/yyyy)

DATE (mm/dd/yyyy)

See Reverse

APPROVED FOR
VA FORM
FEB 2005 (R)

SIGNATURE AND TITLE

(DO NOT SIGN A BLANK FORM)

ACCOUNT SYMBOL

10-2520

VOUCHER AUDIT BLOCK

VOUCHER AUDITOR

DATE

(mm/dd/yyyy)