Old VA Form 10-8678

OMB Approved No. 2900-0198
Respondent Burden:10 Minutes
Expiration: XX/XX/XXXX

APPLICATION FOR ANNUAL CLOTHING ALLOWANCE
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 complete this form is
mandatory. Failure to respond will directly impact the benefits for which you may be entitled. 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.
WHO IS ELIGIBLE FOR AN ANNUAL CLOTHING ALLOWANCE? Veterans who wear or use a qualifying prescribed
prosthetic or orthopedic appliance and/or prescription medication for a service-connected disability or skin condition may be eligible for
an annual clothing allowance. To be eligible, the appliance must wear or tear clothing, or medication must irreparably damage the
veteran's outer-garments.
WHO IS ELIGIBLE FOR MORE THAN ONE ANNUAL CLOTHING ALLOWANCE? Effective December 16, 2011, Veterans
who wear or use more than one qualifying prescribed prosthetic or orthopedic appliance and/or prescription medication for more than
one service-connected disability or skin condition may be eligible for more than one clothing allowance. To be eligible for more than
one clothing allowance, the qualifying appliances must wear or tear more than one type of article of the Veteran's clothing and/or
medications must irreparably damage more than one type of the Veteran's clothing or outer-garment.
WHAT APPLIANCES ARE INCLUDED? Appliances such as an artificial limb, rigid brace, wheelchair, crutches or other appliance
prescribed for the Veteran's service-connected disability. Non-rigid appliances, such as knee, ankle, or elbow sleeves are not included.
Multiple appliances/devices providing similar compensationfor the same disability cause damage to similar clothing items and therefore
are considered as one appliance relative to clothing allowance eligibility. Examples include: 1) a hand-cycle and a wheelchair utilized
by a paraplegic); and 2) a running limb and everyday walking limb used by an amputee.
WHAT MEDICATIONS ARE INCLUDED? Any medication prescribed for a service-connected skin condition that causes permanent
stains or otherwise damages the Veteran's outer garments.
WHAT TYPES OF CLOTHING ARE INCLUDED? Clothing such as shirts, blouses, pants, skirts, shorts and similar garments
permanently damaged by qualifying appliances and/or medications are considered in clothing allowance decisions. Shoes, hats, scarves,
underwear, socks, and similar garments are not included.
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 an application for
disability compensation, complete VA Form 21-526 and send to the VA regional office nearest your home.
WHEN SHOULD I EXPECT PAYMENT OF THE CLOTHING ALLOWANCE? Applications are accepted and processed
throughout the year; however, payments for the current annual clothing allowance year are paid out between September 1 and
October 31. If you have not received your payment by October 31st, please contact your local Prosthetic and Sensory Aids Service.
1. LAST NAME, FIRST NAME, MIDDLE NAME OF VETERAN

2. VETERAN'S SSN

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

4. VETERAN'S DAYTIME TELEPHONE NUMBER (include area code)

4a. EVENING TELEPHONE NUMBER (include area code)

4b. CELL PHONE NUMBER (include area code)

5. CALENDAR YEAR FOR APPLICATION

VA FORM
FEB 2012

10-8678

EXISTING STOCK OF VA FORM 10-8678, APRIL 2008, WILL NOT BE USED

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6. Type of Appliance or Name of
Medication (Artificial leg, metal brace,
wheelchair, etc.)

7. List of Service-Connected
Disability/Disabilities Requiring Use
of Appliance(s) or Medication(s)

8. Month and
Year Appliance
or Medication
was issued
(MM/YYYY)

9. Name and location of VA facility that issued appliance or
medication (if not a VA facility include facility's phone number)

10. List all impacted
location(s)
(Chest, Back, Buttock, Left or
Right Leg, Left or Right Arm)

FOR VA USE
ONLY
APPROVED?

Example A

Yes

No

Example B

Yes

No

1.

Yes

No

2.

Yes

No

3.

Yes

No

4.

Yes

No

5.

Yes

No

6.

Yes

No

7.

Yes

No

8.

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 or disabilities, I regularly wear or use the prosthetic
or orthopedic appliance(s) described above, which tends to wear out or tear my clothing or that, for my service-connected skin condition, I regularly use the medication(s) described above, which causes permantly
damage to my outer clothing. If I have multiple appliances or medications impacting a single outer-garment, the combination of these appliances and/or medications causes me to replace my garment faster than if
I used a single appliance or cream.
yes
no
11. 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.
VA FORM
FEB 2012

10-8678

EXISTING STOCK OF VA FORM 10-8678. APRIL 2008, WILL NOT BE USED

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VETERAN'S SSN

LAST NAME, FIRST NAME, MIDDLE NAME OF VETERAN

FOR VA USE ONLY

#

12. AMOUNT OF CLOTHING ALLOWANCES

ELIGIBLE

#

NOT ELIGIBLE

13. EXAMINATION/EVALUATION DATE (If applicable)

14. NOTES:

# UPPER Extremity

# LOWER Extremity

# UPPER/LOWER Extremity

15. PROCESSED BY:

DATE

16. APPROVED BY:

DATE

17. AUTHORIZED BY: (Required when Veteran is disapproved for multiple clothing allowances
impacting a single garment.)

DATE

VA FORM
FEB 2012

10-8678

EXISTING STOCK OF VA FORM 10-8678, APRIL 2008, WILL NOT BE USED

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