10-1394 Application For Adaptive Equipment Motor Vehicle

OMB Control No. 2900-0188
Estimated Burden: 15 minutes
Expiration Date: XX/XX/20XX

APPLICATION FOR ADAPTIVE EQUIPMENT
AUTOMOBILE OR OTHER CONVEYANCE
Who is eligible for adaptive equipment? A Servicemember or Veteran who meets the criteria as stated in 38 USC Chapter 39 and 38 CFR §§17.156-17.158; and because of a
service connected disability or disabilities is required to obtain equipment to operate, enter and exit an automobile or other conveyance.
Who determines eligibility for adaptive equipment? The Veterans Benefits Administration (VBA) will review and certify whether a Veteran or Servicemember meets the
criteria. An eligible person will receive a certified form 21-4502 annotating an eligibility decision.
Where can I find a copy of my 21-4502? At your local VBA Regional Office or by registering and logging on at: https://www.ebenefits.va.gov/ebenefits/homepage
Who determines entitlement for adaptive equipment? The Veterans Health Administration will review medical documentation and other pertinent information to assist with
the selection of medically appropriate adaptive equipment for operating, and/or entering and exiting your automobile or other conveyance.
What type(s) of automobiles or other conveyances are considered? Automobiles, Minivans, Trucks, Sports Utility Vehicles (SUV), etc. If you are unsure whether your
selection of vehicle or personally owned vehicle can receive the appropriate adaptive equipment, please contact your local VHA Drivers Rehabilitation Specialist or Prosthetic
Representative.
Who is eligible for a payment? A registered provider (manufacturer, modifier, and alterer) who is registered with the National Highway Traffic Safety Administration
(NHTSA) as stated in 38 CFR 17.157.
Who is eligible for a reimbursement? A Veteran or Servicemember.
Where can I find the amounts for payment or reimbursement? The “VA Adaptive Equipment Schedule for Automobile and Other Conveyance” can be found at:
www.prosthetics.va.gov.
What type(s) of documentation is needed? For payments to a registered provider, an eligible person or registered provider must submit an itemized estimate and final itemized
invoice. For reimbursements to an eligible person who purchased adaptive equipment from a registered provider, the eligible person must submit an itemized estimate and final
itemized invoice, paid receipt or bill of sale. For reimbursements to an eligible person who purchased adaptive equipment from an unregistered provider, the eligible person must
submit a final itemized invoice, paid receipt or bill of sale.
Where do I submit my application? Complete all items of Part I and submit to the Prosthetic and Sensory Aids Services at your nearest VA Medical Center.

PART I (To be completed by the Veteran/Servicemember as described in 38 CFR 17.157)
1. Name of Veteran/Servicemember (Last Name, First Name, MI)

2. Veteran/Servicemember SSN

3. Mailing Address of Veteran/Servicemember (Number and Street or Rural Route, City or PO., State and Zip Code)

4. Telephone Number

5. Do you have a valid Driver’s License or Permit in possession?
Yes
No (If no, only entitled to ingress / egress equipment)

(Including Area Code)

6. Do you have a VA Certificate of Eligibility (VA Form 21-4502)
Yes
No

7. Vehicle(s) for which adaptive equipment is prescribed; requesting payment to a registered provided;
reimbursement to a eligible person; or both?
7B. Purchased with
VA Automobile
7C. Year of
7A. Type of Automobile Allowance? (Y/N)
Vehicle
or Conveyance
Automobile
Note: If yes,
or
(e.g., automobile, van,
reimbursement
for some adaptive Conveyance
truck, SUV, other)
(YYYY)
equipment may not
be approved by VA.
Yes

No

Yes

No

7D. Make

7E. Model

7F. Vehicle Identification
Number (VIN)

7G. Date of Adaptive
Equipment Provided
(MM/DD/YYYY).
Note: Complete if
applying for repairs,
replacement or
reinstallations.

CERTIFICATION: I hereby apply for adaptive equipment for the automobile(s) or other conveyance(s) in Item 7 above required for my service-connected disability
(ies). I understand that payments will be remitted only to a registered provider and reimbursements will be remitted to the eligible persons and will not exceed the
amounts listed in the "VA Adaptive Equipment Schedule for Automobile and Other Conveyance." I agree to provide all documentation for payments and
reimbursements before VA will authorize payment or reimbursement. I understand that VA is not responsible for any payment or reimbursement until all requirements
of 38 USC Chapter 39 and 38 CFR §§17.156-17.158 have been met.
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.
8. Signature of Veteran/Servicemember

VA FORM
MAR 2024

10-1394

9. Date (MM/DD/YYYY)

10P4R

PAGE 1

PART II - ENTITLEMENT FOR PAYMENT / REIMBURSEMENT (To be completed by VHA)
10. All documentation for payment and reimbursement has been received?

(NOTE: Attach all documentation when forwarding to VBA for processing).
Yes

11. Date Received (MM/DD/YYYY)

No

12. Are you approving payment?
Yes
No (If no, please send 8-point decision letter along with VA Form 20-0998 with explanation for disapproval)
13. Amount requested for payment

14. Total amount to be paid to registered provider

15. Remit payment to registered provider
Name:
Address:
16. Are you approving reimbursement?
Yes
No (If no, please send 8-point decision letter along with VA Form 20-0998 with explanation for disapproval)
17. Amount requested for reimbursement

18. Total amount to be reimbursed to Veteran/Servicemember

19. Approving Office Name and Title

20. VHA Station Code

21. Signature of Approving Official

22. Date (MM/DD/YYYY)

PART III - PROCESSING PAYMENT / REIMBURSEMENT (To be completed by VBA)
AUTHORIZATION FOR AUTOMOBILE ADAPTIVE EQUIPMENT: The named applicant in Part 1 is eligible under 38 U.S.C. 3901-3904 for payment/ or
reimbursement for prescribed adaptive equipment, subject to certain payment limitations.

I CERTIFY THAT the Veteran, Servicemember, will be reimbursed and/or the registered provider will be paid according to the payment
limitations as listed in Part II of this application
23. Authorizing Office Name and Title

24. VBA Regional Office Code

25. Signature of Authorizing Official

26. Date (MM/DD/YYYY)

VA BURDEN STATEMENT: 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 2900-0188, and it expires XX/XX/20XX. Public reporting
burden for this collection of information is estimated to average 15 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 this burden, to VA Reports
Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0188 in any correspondence. Do not send your
completed VA Form 10-1394 to this email address.
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.

VA FORM 10-1394, MAR 2024

10P4R

PAGE 2