Form VA Form 28-1905m VA Form 28-1905m Request for Supplies (Chapter 31-Vocational Rehabilitati

OMB Approved No. 2900-0061
Respondent Burden: 1 hour

REQUEST FOR SUPPLIES (Chapter 31-Vocational Rehabilitation)
PRIVACY ACT NOTICE: No benefits may be paid unless a completed application form has been received (38 C.F.R. 21.212 and
21.224). The information requested on this form is necessary to determine your entitlement to the benefit for which you have applied.
The responses you submit are considered confidential, 38 U.S.C. 5701. They may be disclosed outside the Department of Veterans
Affairs (VA) only if the disclosure is authorized under the Privacy Act, Including the routine uses identified in the VA system of
records, 58VA21/22, Compensation, Pension, Education and Rehabilitation Records - VA, published in the Federal Register. The
requested information is required to obtain or retain the benefit. Information submitted is subject to verification through computer
matching programs with other agencies.
RESPONDENT BURDEN: We need this information to ensure the VA that the veteran needs the supplies to continue his or her
program and certifies that the veteran’s facility requires the veteran to have the supplies, and that the veteran does not already have
them. We estimate that you will need an average of 1 hour to review the instructions, find the information, and complete this form.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. Valid OMB control
numbers can be located on the OMB Internet Page at www.whitehouse.gov/library/omb/OMBINV.VA.EPA.html#VA. If desired, you
can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
NOTE: SUBMIT TWO COPIES OF THIS FORM TO THE DEPARTMENT OF VETERANS AFFAIRS
FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

REHABILITATION GOAL

VA FILE NUMBER

ADDRESS TO WHICH SUPPLIES MAY BE DELIVERED TO VETERAN (Number and street or rural route, city or P.O., State and ZIP Code)

INSTRUCTIONS TO REHABILITATION SERVICE PROVIDER
A. The Department of Veterans Affairs (VA) may furnish supplies to
B. VA will NOT furnish tools or other supplies which commonly are on
the veteran named above, who is entering or is already in a VA
hand for use of all trainees or employees or which the veteran already
rehabilitation, independent living, or employment assistance program,
owns.
if both of the following conditions are met:
C. If items are required under the conditions stated in A, and are not
being requested merely because the veteran desired them, you may
1. You require all persons being trained for or employed in the same
request these supplies by completing the section immediately following
occupational or independent living goal to personally have the same
these instructions. You may continue to list required items on the reverse
books, tools, and other supplies; and
side of the form and on additional forms.
D. On the reverse of this form, please complete and sign the Request and
2. The veteran does not already have the items which you require.
Certification of Establishment section. Also make sure the veteran signs
the Certification of Veteran section.
(

)

ITEM NO.
(If Applicable)

NAME OF ARTICLE AND DESCRIPTION
(Catalog identification, size, etc.)

QUANTITY
(Set, pair, etc.)

ESTIMATED
COST

$

VA FORM
AUG 2008

28-1905m

SUPERSEDES VA FORM 28-1905m, APR 1998, WHICH WILL
NOT BE USED.

See Reverse

(

)

ITEM NO.
(If applicable)

QUANTITY
(Set, pair, etc.)

NAME OF ARTICLE AND DESCRIPTION
(Catalog identification, size, etc.)

ESTIMATED
COST

$

TOTAL ESTIMATED COST OF REQUESTED SUPPLIES

$

REQUEST AND CERTIFICATION OF ESTABLISHMENT

TO THE DEPARTMENT OF VETERANS AFFAIRS: Please authorize for the veteran the supplies listed above. The veteran is
receiving training, employment, or other rehabilitation services under the VA vocational rehabilitation program. These supplies are not
merely desired by the veteran, but are required to be personally owned by all persons training in, employed by, or receiving
rehabilitation services in this facility or establishment who have the same occupational or independent living goal as the veteran.
If authorized by the Department of Veterans Affairs, this facility or establishment can and will provide the veteran the supplies listed
above which are indicated by the ( ) before the item number or name of the article. These items will be delivered at the prices
indicated under "Estimated Cost".
For supplies which this facility or establishment cannot furnish, we recommend the following vendors:
NAME OF VENDOR

DATE SIGNED

ADDRESS OF VENDOR

SIGNATURE AND TITLE OF OFFICIAL

NAME OF FACILITY OR ESTABLISHMENT

ADDRESS OF FACILITY OR ESTABLISHMENT

CERTIFICATION OF VETERAN
TO THE DEPARTMENT OF VETERANS AFFAIRS: I do not already have in my possession any of the supplies listed above which are usable and available for
use in my rehabilitation.
DATE SIGNED

SIGNATURE OF VETERAN

CERTIFICATION OF OF CASE MANAGER
The above list of supplies is in accord with the limitations and restrictions found in 38 U.S. Code 1504 and in applicable VA regulations.
DATE SIGNED

SIGNATURE OF CASE MANAGER