Form 28-1905m Request and Authorization for Supplies (Chapter 31 - Vet

OMB Approved No. 2900-0061
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

REQUEST AND AUTHORIZATION FOR SUPPLIES (Chapter 31 Veteran Readiness and Employment)

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this form to submit a
request for assistance with obtaining supplies and equipment for Chapter 31 benefits. For more information, contact us at
https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the
Federal relay number is 711. VA forms are available at www.va.gov/vaforms. After completing the form, if returning by mail,
mail to: Veteran Readiness and Employment (VR&E) Intake Center, Department of Veterans Affairs, P.O. Box 5210, Janesville, WI,
53547-5210.

SECTION I: CLAIMANT'S IDENTIFICATION INFORMATION

NOTE: You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable circle to help
expedite the processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)

2. VA FILE NUMBER

3. REHABILITATION PLAN GOAL

4. ADDRESS WHERE SUPPLIES WILL BE DELIVERED TO CLAIMANT (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

Apt./Unit Number

City
Country

State/Province

ZIP Code

5. TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)

6. EMAIL ADDRESS (Optional)

I agree to receive electronic correspondence from VA in regards to my claim.

SECTION II: REQUEST AND CERTIFICATION OF TRAINING AND EMPLOYMENT FACILITY
The Department of Veterans Affairs (VA) will furnish supplies and/or equipment to the claimant named above, who is participating in a rehabilitation plan
of services if one of the following criteria applies - 1). The supplies or equipment are required for one of the following reasons: to be used by all
individuals in the claimant's program, to compensate for the effects of the claimant's disabilities, or to allow the claimant to function more independently
and lessen his or her dependence on others [38 CFR 21.212(b)], or 2). The VA case manager has determined that the supplies or equipment are needed
and both of the following criteria are met - a). The items are generally owned and used by students or employees pursuing the training, independent
living, or employment objective, and b) individuals who do not have the items would be placed at a distinct disadvantage [38 CFR 21.212(d)].
If the facility or employer requires the claimant to personally possess the supplies or equipment, the facility representative or employer must specify
these and sign in Section III below. If the VA case manager determines that the supplies and/or equipment are needed or required, signature from the
facility or employer representative is not necessary. The case manager must review the request and sign in Section III below. The claimant's signature in
Section III verifies that the requested items are needed or required based on the conditions listed above and will be used during his or her rehabilitation
plan of services.
7. NAME OF ITEM AND DESCRIPTION

8. QUANTITY

9. ESTIMATED COST
$

$

$

$

VA FORM
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28-1905m

SUPERSEDES VA FORM 28-1905M, APR 2015,
WHICH WILL NOT BE USED.

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$

$

$

$

$

$

$

$

$

SECTION III: CERTIFICATION AND SIGNATURE

I CERTIFY THAT I have filled this form out completely and that it is true and correct to the best of my knowledge and belief.
10A. SIGNATURE AND TITLE OF TRAINING FACILITY OR EMPLOYER
REPRESENTATIVE

10B. DATE SIGNED (MM/DD/YYYY)

10C. NAME AND ADDRESS OF TRAINING FACILITY OR EMPLOYER (Number and Street, City, State, and ZIP Code)

Apt./Unit Number
State/Province

City
Country

ZIP Code

10D. CLAIMANT SIGNATURE (REQUIRED)

10E. DATE SIGNED (MM/DD/YYYY)

10F. CASE MANAGER SIGNATURE

10G. DATE SIGNED (MM/DD/YYYY)

PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or for fraudulent
receipt of any document you are not entitled to.
PRIVACY ACT NOTICE: The responses you submit are considered confidential (38 U.S.C. 5701). Your obligation to respond is required in order to obtain benefits. VA will not disclose
information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or
criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party
or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records,
58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Information that you furnish may be
utilized in computer matching programs with other Federal or State agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the
United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: This form is used to submit a request for assistance with obtaining supplies and equipment by a Chapter 31 claimant (38 U.S.C. 3104). Title 38, United States
Code, allows VA to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete this form. VA cannot
conduct or sponsor a collection of information unless a valid Office of Management and Budget (OMB) control number is displayed. You are not required to respond to a collection of
information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM
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28-1905m

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