10-1394 Application For Adaptive Equipment Motor Vehicle

OMB Number: 2900-0188
Estimated Burden: 15 minutes

APPLICATION FOR ADAPTIVE EQUIPMENT
MOTOR VEHICLE

PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C., Veterans Benefits, and will be

used to determine your eligibility/entitlement and reimbursement of individual claims for automotive adaptive equipment, and identify your medical
records. Additional information may be solicited during the course of processing your application. The information you supply may also be disclosed
outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records" 24VA136, published in the Federal Register. Disclosure is
voluntary, however, failure to furnish the information will result in our inability to process your request promptly and serve your medical needs. Failure to
furnish the information will have no adverse effect on any other benefits to which you may be entitled.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of

section 3507 of the Paperwork Reduction Act of 1995. 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 individuals who must complete this form will average 15 minutes. This
includes the time it will take to read instructions, gather the necessary facts and fill out the form.
PART I - (To be completed by applicant-If more space is needed, attach a separate sheet and identify by item number.)
1. VETERAN'S NAME AND ADDRESS
(This is a mandatory field.)

2. CLAIM NUMBER

3. SOCIAL SECURITY NUMBER
(This is a mandatory field.)

C6. DATE OF VA CERTIFICATE OF ELIGIBILITY

5. YEAR YOU RECEIVED GRANT FOR VEHICLE

4. DRIVER'S LICENSE VERIFICATION (Check applicable block)

(If January 11, 1971 or after)

(If prior to January 11, 1971)

VALID LICENSE OR PERMIT IN POSSESSION

(mm/dd/yyyy)

(mm/dd/yyyy)

NOT LICENSED

7. DISABILITIES - Check applicable box(es)

EXTREMITY
AND LEVEL

8. DESCRIPTION OF VEHICLE FOR WHICH ADAPTIVE EQUIPMENT IS REQUIRED

AMPUTATlON

ANKYLOSIS

LOSS OF USE

LEFT

LEFT

LEFT

RIGHT

RIGHT

8A. DATE PURCHASED

8B. YEAR

8C. MAKE

8D. MODEL

9B. MAKE

9C. MODEL

RIGHT

A. ARM AE

8E. VEHICLE IDENTIFICATION NUMBER

B. ARM BE
9. LAST VEHICLE FOR WHICH
ADAPTIVE EQUIPMENT WAS
PROVIDED

C. LEG AK (hip)
D. LEG BK (knee)

9A. YEAR

E. OTHER DISABILITIES AFFECTING DRIVING
9D. VEHICLE IDENTIFICATION NUMBER

9E. DATE ADAPTIVE EQUIPMENT PROVIDED
(mm/dd/yyyy)

10. LIST OF ADAPTIVE EQUIPMENT REQUESTED (Check items required)

*NOTE: ALL VAN MODIFICATIONS REQUIRE PRIOR AUTHORIZATION BEFORE PURCHASE
ESTIMATED
COST

DESCRIPTION

X

$

A. AUTOMATIC TRANSMISSION

ESTIMATED
COST

DESCRIPTION

X

$

K. TRANSFER OF CONTROLS

B. POWER BRAKES

L. HAND CONTROLS--ACCELERATOR & BRAKE

C. POWER STEERING

M. *SENSITIZED/LOW EFFORT BRAKE

D. POWER SEAT (6 way/2 way)

N. *SENSITIZED/LOW EFFORT STEERING

E. POWER WINDOWS

O. *DROP FLOOR

F. TILT STEERING WHEEL

P. *RAISED ROOF

G. CRUISE CONTROL

O. *POWER DOOR OPENERS

H. REAR WINDOW DEFROSTER

R. *VAN LIFT

I. FOOT/HAND OPERATED PARKING BRAKE

S. *POWER TRANSFER SEAT

J. AIR CONDITIONER

T. *OTHER (Describe)

U. JUSTIFICATION (Include full description and estimated cost of item T, if applicable)

11. MAKE PAYMENT TO THE FOLLOWING (Check appropriate box(es) and attach a certified invoiced:)

AMOUNT TO BE PAID

$

A. AUTOMOTIVE DEALER
B. ADAPTIVE EQUIPMENT SUPPLIER
C. PERSONAL REIMBURSEMENT
D. FULL NAME AND ADDRESS WHERE PAYMENT SHOULD BE MADE

E. FULL NAME AND ADDRESS WHERE PAYMENT SHOULD BE MADE

12. STATUS OF APPLICANT (Check one)

13. SIGNATURE OF APPLICANT

VETERAN

VA FORM
FEB 2007 (R)

10-1394

14. DATE

(mm/dd/yyyy)

MEMBER OF ARMED FORCES

PAGE 1 OF 2

PART II - ELIGIBILITY (To be completed by Eligibility Clerk or Designee)
15. APPLICANT IS ELIGIBLE UNDER (Check
INELIGIBLE

one)

16. SIGNATURE AND TITLE OF ELIGIBILITY CLERK OR DESIGNEE

17. DATE

PUB. L. 97-66

PUB. L. 91-666 (VAF 4-4502)

OTHER

(Specify)

PUB. L. 96-466

PART III - APPROVAL AND AUTHORIZATION (TO BE COMPLETED BY PROSTHETIC REPRESENTATIVE)

18. The following adaptic equipment is approved for inclusion with or installation on the specific vehihicle described in item 8 on the
front of this form. Costs including installation, unless authorized separately, will not exceed the total amount indicated for each item.
MAXIMUM
COST

ITEMS AUTHORIZED

MAXIMUM
COST

ITEMS AUTHORIZED

$

$

19. REIMBURSEMENT OR PAYMENT TO THE VENDOR(S) OR INDIVIDUAL(S) NAMED BELOW, IN THE TOTAL AMOUNTS SPECIFIED FOR EACH, IS AUTHORIZED AS A
PROPER CHARGE FOR ADAPTIVE EQUIPMENT PREVIOUSLY PURCHASED BY THE APPLICANT UNDER AUTHORITY OF CFR 3.808:
19A. NAME AND ADDRESS OF PAYEE

19B. AMOUNT

19C. NAME AND ADDRESS OF PAYEE

$
20. NAME AND ADDRESS OF VA FIELD FACILITY

21. SIGNATURE AND TITLE OF AUTHORIZING OFFICIAL

19D. AMOUNT

$
22. DATE

(mm/dd/yyyy)

PART IV - CERTIFICATION OF RECEIPT (TO BE COMPLETED BY APPLICANT)
I CERTIFY THAT I have received the items
or services authorized in item 18 above.

23. SIGNATURE OF APPLICANT

24. DATE (mm/dd/yyyy)

INSTRUCTIONS TO VETERAN OR SERVICEPERSON
1. Contact should be made with the Prosthetics Service at your local VA medical center or outpatient clinic prior to any purchase of equipment.
2. Complete all item in Part I of this form in duplicate and sign the form.
3. If you are requesting adaptive equipment or services, VA will determine your eligibility and complete Part II.
4. After approval, you may give the original of this form to the seller/vendor of your choice, who will deliver the equipment or services authorized
(see also paragraphs 3 and 4 below).
5. In the event you must obtain some of the equipment on a mail-order basis, or cannot use this authorization for any other reason, you may pay
for an authorized item or service and apply for reimbursement from VA. In such cases, you must present a paid invoice properly certified (see
paragraph 2 below).
6. After receipt of the items or services authorized, sign and date the receipt in items 23 and 24, and direct the seller/vendor's attention to the
instructions below. This certification signifies that the adaptive equipment, installation, or service is satisfactory, the servicing information on the
invoice has been verified to the best of your ability and the charges appear to be reasonable.
INSTRUCTIONS TO SELLER/VENDOR
1. This is to inform you that if Part II and III of this form have been completed and signed by VA, the individual who is designated in this form as the
applicant has been authorized the services listed in the attached VA Form 10-2421 (for repairs) or the services listed in Item 18 of this form. Note
that the applicant is not entitled to services that exceed the maximum costs, specified on VA Form 10-2421 or item 18 of this form.
2. After you and the applicant have entered into an agreement for the repair on the attached VA Form 10-2421 or the services listed in item 18, and
you have completed those repairs or services, you may use the following reimbursement procedures. For repairs, complete all copies of the VA Form
10-2421 (if attached), and attach the original and copy 2 to the original of this form. For other items or services, or if no VA Form 10-2421 is
attached, prepare your own invoice, itemizing each separate item or service provided with the cost of each. Identify the make, model, and year of the
automobile or other conveyance and include the following certification specimen on either VA Form 10-2421 or your own invoice, as appropriate:
"I certify that the amounts billed hereon do not exceed the usual and customary costs for the items or services furnished."
Signature of Company Official
3. Attach 2 copies of VA Form 10-2421 or 1 copy of your certified invoice to the original of this form and mail to the VA Office shown in item 20.
4. Ensure that the applicant has signed in items 13 and 23 for receipt of the items or services.
5. VA expressly disavows any intent to enter into a contract with the seller; any agreement as to repairs or other services is between the seller/vendor
and the applicant.

VA FORM
FEB 2007 (R)

10-1394

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