Form VA Form 10-8678 VA Form 10-8678 Application for Annual Clothing Allowance Under Title 38

OMB Approved No. 2900-0198
Respondent Burden:10 Minutes

APPLICATION FOR ANNUAL CLOTHING ALLOWANCE (Under 38 U.S.C. 1162)
PRIVACY ACT INFORMATION: No benefits may be granted unless this form is completed fully as required by law (38 C.F.R.
3.810). Responses you submit are considered confidential (38 U.S.C. 5701). They may be disclosed outside VA only if the disclosure is
authorized under the Privacy Act, including the routine uses identified in the VA system of records, 24VA136 “Patient Medical Record
- VA”, published in the Federal Register. Information submitted is subject to verification through computer matching programs with
other agencies.
RESPONDENT BURDEN: VA may not conduct or sponsor, and the respondent is not required to respond to this collection of
information unless it displays a valid OMB Control Number. Public reporting burden for this collection of information is estimated to
average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Your obligation to respond is voluntary. If you
have comments regarding this burden estimate or any other aspect of this collection of information, call 1-877-222-8387 for mailing
information on where to send your comments.
IMPORTANT: Please read the instructions below carefully, before completing the form.
1. FIRST NAME, MIDDLE NAME, LAST NAME OF VETERAN

2. LAST FOUR DIGITS OF VETERAN'S SSN.

3. ADDRESS OF VETERAN (No. and Street or Rural Route, City or P.O., State and
Zip Code) If new address check box.

4. DISABILITY REQUIRING USE OF THE APPLIANCE OR
MEDICATION

6. TYPE OF APPLIANCE OR NAME OF MEDICATION (Artificial leg, metal
brace, wheelchair, etc.)

YES
NO
5. IS THIS DISABILITY SERVICE CONNECTED?
7. NAME AND LOCATION OF VA MEDICAL CENTER OR OTHER
INSTITUTION WHICH ISSUED APPLIANCE OR MEDICATION AND
PHONE NUMBER IF IT IS NOT A VA FACILITY.

8. MONTH AND YEAR VETERAN WAS ISSUED APPLIANCE/MEDICATION
9. DO YOU HAVE A POWER OF ATTORNEY? (If "Yes", please identify name and/or Organization)

YES

NO

CERTIFICATION: I hereby apply for annual clothing allowance under 38 U.S.C. 1162. In doing so I certify that, because of my service-connected
disability, I regularly wear or use the prosthetic or orthopedic appliance described above, which tends to wear out or tear my clothing or that, for my
service-connected skin condition, I regularly use the medication described above, which causes irreparable damage to my outer clothing.
10. SIGNATURE OF VETERAN

DATE

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any
statement or evidence of a material fact, knowing it to be false, or for the fraudulent acceptance of any payment to which you are not
entitled.
FOR VA USE ONLY
12. EXAMINATION/EVALUATION DATE (If applicable)

11. CHECK OFF BOXES:
STATIC

NON-STATIC

NOT ENTITLED

13. PROCESSED BY:

DATE

14. AUTHORIZED/APPROVED BY:

DATE

SUPERSEDES VA FORM 21-8678, MARCH 2006,
WHICH WILL NOT BE USED.
VA FORM
AUG 2009

10-8678

INFORMATION AND INSTRUCTIONS COVERING APPLICATION FOR
ANNUAL CLOTHING ALLOWANCE
WHO IS ENTITLED TO AN ANNUAL CLOTHING ALLOWANCE? Veterans, who because of a service-connected
disability, wear or use a prosthetic or orthopedic appliance (including a wheelchair) which tends to wear out or tear clothing, and
veterans, who because of a service-connected skin condition use a medication that causes irreparable damage to outer garments, are
eligible for payment of an annual clothing allowance. To qualify for annual payment, eligibility must be established as of August 1
of the year for which payment is claimed. If you have not submitted a claim for disability compensation, VA Form 21-526 must be
completed and sent to the VA Regional Office nearest your home. You can also apply for disability compensation on our website at
http://www.vba.va.gov.
WHAT APPLIANCES ARE INCLUDED? Appliances such as an artificial limb, rigid extremity brace, rigid spinal or cervical
brace, wheelchair, crutches or other appliance prescribed for the claimant's service-connected disability. Soft and flexible devices,
such as an elastic stocking are not included.
WHAT MEDICATIONS ARE INCLUDED? Any medication, prescribed by a physician for a service-connected skin condition,
that causes permanent stains or otherwise damages the veteran's outer garments.
WHERE TO FILE A CLAIM? If you have previously submitted a claim for disability compensation, send this application (VA
Form 10-8678) to the Prosthetic and Sensory Aids Service (121), at your local VA Medical Center. If you have not made
application for disability compensation, send that form (VA Form 21-526) to the VA regional office nearest your home.
WHEN SHOULD I EXPECT PAYMENT OF THE CLOTHING ALLOWANCE? Applications are collected throughout the
year and held until the closing date of August 1st. They are then processed and veterans will receive payments between September
1st and October 31st. This is an annual payment and will only be made during this time frame. If you have not received your
payment by October 31st, you should contact your Prosthetics and Sensory Aids Service.

VA FORM
AUG 2009

10-8678