VA Form 28-1905m Request and Authorization for Supplies and Direct Reimbu

OMB Approved No. 2900-0061
Respondent Burden: 30 minutes
Expiration Date: XX/XX/20XX
VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

REQUEST AND AUTHORIZATION FOR SUPPLIES AND DIRECT REIMBURSEMENT
(Chapter 31 - Veteran Readiness and Employment)
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 3. Use this
form to submit a request for assistance with obtaining supplies and equipment and/or direct reimbursement needed
or required to complete your Chapter 31 program. For more information, contact us at https://ask.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 box to
help expedite the processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)

2. VA FILE NUMBER (If applicable)

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

State/Province

Country

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 FOR PURCHASE OR DIRECT REIMBURSEMENT FOR SUPPLIES AND/OR SERVICES
NOTE: Claimants are required to complete this section and provide the supportive information for request of purchase or direct reimbursement.
The Department of Veterans Affairs (VA) will furnish goods and/or services to the claimant named above, who is participating in a rehabilitation plan of
services if one of the following criteria applies - 1). The goods and/or services 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 goods and/or services 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)].
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. For Direct Reimbursement, the claimant's signature also verifies the item(s) or service(s) were received on
the dates listed in Item 11.
11. ITEM/SERVICES RECEIVED
9. ESTIMATED COST
10. ACTUAL COST
7. NAME OF ITEM/SERVICES
ON THIS DATE
8. QUANTITY
(Government Purchase Card)
(Direct Reimbursement)
AND DESCRIPTION
(Direct Reimbursement)

VA FORM
XXX XXXX

28-1905m

$

$

$

$

$

$

$

$

SUPERSEDES VA FORM 28-1905M, JUL 2021,
WHICH WILL NOT BE USED.

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SECTION II: REQUEST FOR PURCHASE OR DIRECT REIMBURSEMENT FOR SUPPLIES AND/OR SERVICES (Continued)
$

$

$

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$

SECTION III: CERTIFICATION AND SIGNATURE OF CLAIMANT
I CERTIFY THAT I have filled in this form completely and that it is true and correct to the best of my knowledge and belief.
12A. CLAIMANT SIGNATURE (REQUIRED)

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

SECTION IV: CERTIFICATION AND SIGNATURE OF TRAINING FACILITY OR EMPLOYER (If applicable)

If the facility or employer requires the claimant to personally possess the goods and/or services, the facility representative or employer must
specify these and sign in Section II and IV. If the VA case manager determines that the goods and/or services 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 II and IV.
I CERTIFY THAT the items listed in Section II, Item 7 are required of all students or all employees.
13A. NAME AND ADDRESS OF TRAINING FACILITY OR EMPLOYER (Number and Street or rural route, P.O. Box, City, State, ZIP Code and Country)
Name of Training Facility
or Employer
No. &
Street

City

Apt./Unit Number
State/Province

Country

ZIP Code

13B. SIGNATURE AND TITLE OF TRAINING FACILITY OR EMPLOYER
REPRESENTATIVE

13C. DATE SIGNED (MM/DD/YYYY)

14A. NAME OF CASE MANAGER (First, Middle Initial, Last)

14B. SIGNATURE OF CASE MANAGER

VA FORM 28-1905m, XXX XXXX

14C. DATE SIGNED (MM/DD/YYYY)

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FOR VA USE ONLY
REGIONAL OFFICE NUMBER:
SECTION V: AUTHORIZATION FOR DIRECT REIMBURSEMENT
NOTE: Case Managers are required to complete this section and provide the supportive information approved for direct reimbursement.
15A. NAME OF ITEMS OR SERVICES

15B. ACTUAL AMOUNT TO BE REIMBURSED
$
$

$

$

$

$
$

$

$

NOTE: Use continuation sheet(s) if necessary. Payee must NOT use the space below.

15C. TOTAL ►

$

SECTION VI: CERTIFICATION BY DESIGNATED VR&E OFFICER IN VR&E DIVISION
16A. I CERTIFY THAT the cost and items listed in Section V of this form are authorized for reimbursement.
16B. I CERTIFY THAT the cost of incidental supplies and services exceeds $2,500 of training costs for any 12 month period per 38 CFR 21.156(b).
NOTE: If box 16B is checked, the Certifying Official in 16C must be a VR&E Officer.
16C. NAME AND TITLE OF AUTHORIZED CERTIFYING OFFICIAL
TITLE:
16D. SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

16E. DATE SIGNED (MM/DD/YYYY)

SECTION VII: ACCOUNTING CLASSIFICATION (For completion by Finance Activity)
17A. NAME OF PAYEE (First, Middle Initial, Last)

17B. AMOUNT REIMBURSED
$

.

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). The information requested on this form is required under the provisions of 31 U.S.C.
3325, for the purpose of disbursing Federal money. The information requested is needed to identify the particular creditor and the amounts to be paid. Failure to furnish this information will
hinder discharge of the payment obligation. 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 Veteran Readiness 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: 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 2900-0061, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 30 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. 2900-0061 in any correspondence. Do not send your completed VA Form 28-1905m to this email address.
VA FORM 28-1905m, XXX XXXX

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