26-4555 Application in Acquiring Specially Adapted Housing or Sp

OMB Approved No. 2900-0132
Respondent Burden: 10 minutes
Expiration Date: XX-XX-20XX

APPLICATION IN ACQUIRING SPECIALLY ADAPTED HOUSING OR
SPECIAL HOME ADAPTATION GRANT
(Title 38 U.S.C. Section 2101(a) or 2101(b))
PRIVACY ACT NOTICE: 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, CFR 1.576 for routine uses (for example: Authorizing release of information to Congress when requested for statistical purposes) identified in the VA
system of records, 55VA26, Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant Records,
and Vendee Loan Applicant Records - VA, published in the Federal Register. Your response is required to obtain or retain benefits. Giving us your SSN account
information is mandatory. Applicants are required to provide their SSN under Title 38, CFR 3.809. The VA will not deny an individual benefits for refusing to provide
his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 2900-0132, and it expires XX/XX/20XX. Public reporting burden for this collection
of information is estimated to average 10 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB
Control No. 2900-0132 in any correspondence. Do not send your completed VA Form 26-4555 to this email address.

INSTRUCTIONS: This application should be submitted to the VA regional office where your claim file is located or this form can be
completed online by visiting www.ebenefits.va.gov.
1. FIRST NAME - MIDDLE INITIAL - LAST NAME

2. SOCIAL SECURITY NO.

4. DATE OF BIRTH (MM/DD/YYYY)

5. E-MAIL ADDRESS

3. VA FILE /CLAIM NUMBER

6. ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

7. TELEPHONE NUMBERS OF APPLICANT (Include Area Code)
A. DAYTIME

B. EVENING

C. CELL

8. HAVE YOU MADE PREVIOUS APPLICATION FOR SPECIALLY ADAPTED HOUSING?
YES

NO

(If "Yes," give date (MM/DD/YYYY) and place)

9. HAVE YOU MADE PREVIOUS APPLICATION FOR HOME IMPROVEMENT AND STRUCTURAL ALTERATION GRANT?
YES

NO

(If "Yes," give date (MM/DD/YYYY) and place)

10. ARE YOU CONFINED TO A NURSING HOME OR MEDICAL CARE FACILITY?
YES

NO

(If "Yes," give name and address of facility)

11. REMARKS

CERTIFICATION
I am applying for assistance in acquiring specially adapted housing or special home adaptation grant because of the nature of my service-connected disability. I
understand that there are medical and economic features yet to be considered before I am eligible for this benefit, and that I will be notified of the action taken on this
application as soon as possible.
12A. SIGNATURE OF APPLICANT (Sign full name in ink.)

12B. DATE SIGNED (MM/DD/YYYY)

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.
VA FORM
XXXX

26-4555

SUPERSEDES VA FORM 26-4555, JUN 2021,
WHICH WILL NOT BE USED.