Form 21-4502 Application for Automobile or Other Conveyance and Adapt

OMB Control No. 2900-0067
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR AUTOMOBILE OR OTHER CONVEYANCE
AND ADAPTIVE EQUIPMENT (UNDER 38 U.S.C. 3901-3904)
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent on page 2. Use this form to apply for automobile
or other conveyance and adaptive equipment allowance (38 U.S.C. Chapter 39). For more information, contact us at https://ask.va.gov/,
or call us toll-free at 1-800-827-1000 (TTY: 711). VA forms are available at www.va.gov/vaforms. After completing the form, mail to:
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.

SECTION I - VETERAN/SERVICEMEMBER'S IDENTIFICATION INFORMATION

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, and
completely fill in each applicable checkbox to help expedite processing of the form.
1. VETERAN/SERVICE MEMBER'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER (If applicable)

2. SOCIAL SECURITY NUMBER

5. VETERAN'S SERVICE NUMBER (If applicable)

7. E-MAIL ADDRESS

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

Enter International Phone Number (If applicable)

6. TELEPHONE NUMBER (Include Area Code)

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

NOTE: A service member planning early release should give both present military address and planned address following release from active duty, in Items 8A and 8B.
8A. CURRENT ADDRESS (No. and Street or rural route, City or P.O., State and Zip Code)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

8B. SERVICE MEMBER'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY (No. and Street or rural route, City or P.O., State and Zip Code)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

SECTION II - APPLICATION INFORMATION
9. BRANCH OF SERVICE
ARMY

NAVY

10. ARE YOU ON ACTIVE DUTY?
MARINE CORPS

AIR FORCE

COAST GUARD

SPACE FORCE

NOAA

USPHS

YES

NO

11A. PLACE OF ENTRY INTO ACTIVE DUTY

11B. DATE OF ENTRY (MM/DD/YYYY)

11C. PLACE OF RELEASE FROM ACTIVE DUTY (If applicable)

11D. DATE OF RELEASE (MM/DD/YYYY)

12A. HAVE YOU APPLIED FOR VA DISABILITY
COMPENSATION? (If "Yes," specify name of place)
YES

12B. DATE YOU APPLIED (MM/DD/YYYY)

13. LOCATION OF VA OFFICE THAT HAS YOUR FILE (If known)

NO

14. TYPE OF CONVEYANCE APPLIED FOR (Check one)
AUTOMOBILE

STATION WAGON

VAN

TRUCK

OTHER (Specify)

15. HAVE YOU PREVIOUSLY APPLIED FOR AN AUTOMOBILE OR OTHER CONVEYANCE?
YES

NO

(If "Yes," give date (mm/dd/yyyy) and place)

Place:

I HEREBY APPLY for the conveyance checked in Item 14 above and the equipment required because of my disability. I agree that before operating the vehicle I shall
hereafter apply to the proper authority for the necessary license to operate it. If I am unable to qualify for a license, I certify that a person licensed to operate a similar
vehicle in the state of my residence will operate the vehicle for me. I FURTHER CERTIFY that VA has not previously paid an automobile grant on my behalf or that
either (1) the automobile previously purchased with assistance was destroyed as a result of a natural or other disaster, or (2) it has been 30 or more years since my most
recent automobile grant. I understand that I must contact my local Veterans Health Administration (VHA) Prosthetic and Sensory Aids Service prior to obtaining any (new
or used) adaptive equipment and that VA may deny claims for payment or reimbursements if eligibility has not been established or has been terminated.
16. SIGNATURE OF VETERAN OR SERVICE MEMBER (REQUIRED)

VA FORM
XXX XXXX

21-4502

17. DATE SIGNED (MM/DD/YYYY)

SUPERSEDES VA FORM 21-4502, JUL 2021.

PAGE 1

VETERAN/SERVICE MEMBER'S SOCIAL SECURITY NO.

SECTION III - CERTIFICATE OF ELIGIBILITY (To be completed by VA)
QUALIFYING DISABILITIES (Check appropriate box(es))
18A. LOSS OF FOOT
RIGHT

LEFT

18B. LOSS OF HAND
BOTH

RIGHT

18C. PERMANENT LOSS OF USE OF FOOT

LEFT

BOTH

19. PERMANENT IMPAIRMENT OF VISION

RIGHT

LEFT

20. SEVERE BURN INJURY

CENTRAL VISUAL ACUITY 20/200 OR LESS IN THE BETTER EYE
WITH CORRECTIVE GLASSES

YES

18D. PERMANENT LOSS OF USE OF HAND

BOTH

NO

RIGHT

LEFT

BOTH

21. AMYOTROPHIC LATERAL SCLEROSIS
(ALS)
YES

NO

CONTRACTION OF THE PERIPHERAL FIELD OF VISION TO 20
DEGREES OR LESS IN THE BETTER EYE

22. Authorization for Allowance for Automobile or Other Conveyance: The above-named applicant is eligible under 38 U.S.C. 3901-3904 to purchase the automobile
or conveyance shown in Item 14, subject to certain payment limitations. VA cannot pay more than the rate in effect when VA receives the claim for payment from the
seller. The allowance includes applicable taxes when included in the purchase price. The allowance does not include payment for any adaptive equipment specified for the
qualifying disabilities.
Adaptive Equipment: The cost of adaptive equipment and its installation may be reimbursed. Adaptive equipment is not provided if the claimant is blind, requires a
driver, or does not have a valid State driver's license or learner's permit. See the attached list for the adaptive equipment that is authorized for the qualifying disabilities
shown above. All additional add-on equipment must be approved by VA. If this is an additional automobile (the automobile previously purchased with assistance was
destroyed as a result of a natural or other disaster, or 30 or more years since the most recent automobile grant), the veteran must contact their local VHA Prosthetic and
Sensory Aids Service prior to obtaining any (new or used) adaptive equipment. VA may deny claims for payment or reimbursements if eligibility has not been established
or has been terminated.
I CERTIFY THAT the veteran has not previously received an allowance for automobile or other conveyance under 38 U.S.C. 3901-3904. If this is an additional
automobile, I certify that either the automobile previously purchased with assistance was destroyed as a result of a natural or other disaster, or it has been 30 or more
years since the most recent automobile grant.
23. NAME AND LOCATION OF VA OFFICE

24B. DATE SIGNED (MM/DD/YYYY)

24A. SIGNATURE OF CERTIFYING OFFICIAL

TITLE OF CERTIFYING OFFICIAL
26. YEAR (YYYY)

25. MAKE AND MODEL

27. VEHICLE IDENTIFICATION NO. (VIN)

$
30A. I WILL OPERATE THIS VEHICLE
YES

29. DATE OF SALE (MM/DD/YYYY)

28. TOTAL PURCHASE PRICE

NO

31. NAME OF SELLER

,

.
30B. I HAVE A VALID STATE DRIVER'S LICENSE OR LEARNER'S PERMIT
YES

NO

32. ADDRESS OF SELLER

I hereby acknowledge receipt of the automobile or other conveyance with the adaptive equipment specified on attached invoice.
33A. SIGNATURE OF VETERAN OR SERVICE MEMBER (REQUIRED)

33B. DATE OF RECEIPT (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, or for the fraudulent acceptance of any payment to which you are not entitled.
PRIVACY ACT INFORMATION: 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. Your obligation to respond 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 USC
5101 (c)(1). 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. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential
(38 U.S.C. 5701).
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 2900-0067, 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 the burden, to VA Reports Clearance Officer
at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0067 in any correspondence. Do not send your completed VA Form 21-4502 to this email address.

VA FORM 21-4502, XXX XXXX

PAGE 2

INFORMATION AND INSTRUCTIONS
If you have questions about this form, how to fill it out, or about benefits, contact us online at https://ask.va.gov/ or call us VA toll-free at 1-800-827-1000 (TTY: 711.)
A. What are automobile and adaptive equipment benefits and how does VA
decide what I will or will not receive?
1. Allowance towards purchase of a vehicle - Veterans who are receiving
compensation under 38 U.S.C. 1151 for any of the following disabilities are also
eligible. Effective January 5, 2023, claimants may receive an additional vehicle or
conveyance if more than 30 years have elapsed since the eligible person most
recently received an automobile or other conveyance. The amount paid is limited
by law. Contact https://www.va.gov/disability/compensation-rates/special-benefitallowance-rates/ for the current rate.
Additionally, VA may provide or assist in providing an eligible person with a
second automobile or other conveyance if: VA receives satisfactory evidence that
the automobile or other conveyance previously purchased with this assistance was
destroyed as a result of a natural or other disaster, as determined by VA; and
• through no fault of the eligible person; and
• the eligible person does not otherwise receive from a property insurer
compensation for the loss.
A veteran or service member must possess one of the following disabilities as a
result of injury or disease incurred or aggravated during active military service:
• loss or permanent loss of use of one or both feet, or
• loss or permanent loss of use of one or both hands, or
• permanent impairment of vision in both eyes with a
• central visual acuity of 20/200 or less in the better eye with corrective
glasses, or
• central visual acuity of more than 20/200 if there is a field defect in
which the peripheral field has contracted to such an extent that the
widest diameter of visual field has an angular distance no greater
than 20 degrees in the better eye, or
• Severe burn injury: Deep partial thickness or full thickness burns resulting in
scar formation that cause contractures and limit motion of one or more
extremities or the trunk and preclude effective operation of an automobile, or
• amyotrophic lateral sclerosis (ALS).
Important: VA is required by law to pay the benefit to the seller of the
vehicle. Payment cannot be made to the veteran or service member. Do not
purchase a vehicle until authorized by VA.
2. Adaptive equipment
A veteran or service member who qualifies for the automobile allowance also
qualifies for adaptive equipment. VA must approve all adaptive equipment as
prescribed by a VHA provider. Contact https://www.prosthetics.va.gov/psas/
index.asp for more information on how to receive adaptive equipment. Note:
Note: Adaptive equipment may be provided for no more than two vehicles in a
four-year period. See Page 4 for more information about adaptive equipment.
Important: VA will not pay for the purchase of add-on adaptive equipment
(equipment furnished by someone other than the automobile manufacturer) that is
not approved by VA. Contact the nearest VA health care facility for more
information on add-on equipment. The adaptive equipment benefit may be paid to
either the seller or the veteran or service member.
3. Special drivers training is available for disabled veterans or service members,
who should contact the nearest VA health care facility to request this training at
https://www.rehab.va.gov/pmrs/Drivers_Rehabilitation_Program.asp.

VA FORM 21-4502, XXX XXXX

B. What conveyance may be purchased?
You may purchase a new or used automobile, or other conveyance, if approved by
VA.
VA recommends that you consult with a VA healthcare provider prior to selecting
a vehicle or other conveyance to ensure your adaptive equipment is compatible
with a specific vehicle make/model.
C. When should VA Form 21-4502 be submitted?
There is no time limit for filing a claim; however, the claim must be authorized by
VA before you purchase the automobile or conveyance.
D. Instructions to veteran or service member
1. Complete all items of Section I and II and submit to VA. Send the form to your
nearest VA regional office.
2. VA will determine your eligibility and, if eligibility exists, VA will complete
Section III and return the form to you.
3. Purchase a vehicle. When you receive the vehicle and the adaptive equipment
from the seller, complete Section IV. If you need adaptive equipment, contact the
Prosthetic and Sensory Aids Service at: https://www.prosthetics.va.gov/psas/
index.asp, for more information on how to receive adaptive equipment.
4. Give the original VA Form 21-4502 to the seller.
5. Submit any invoices for adaptive equipment and/or installation not included on
the seller's invoice to the nearest VA health care facility. These invoices,
identified with your full name and VA file number, must show the itemized net
cost of any adaptive equipment and installation charges, any unpaid balance, and
the make, year and model of the vehicle to which the equipment is added.
Reminder: VA must approve all adaptive equipment as prescribed by a VHA
provider prior to purchase.
E. Instructions to seller
1. Make sure that Section III of VA Form 21-4502 is completed and signed by
VA.
2. For initial automobile allowance grants, deliver the vehicle, including VAapproved adaptive equipment provided and/or installed by the seller.
3. Obtain the original copy of VA Form 21-4502 from the veteran or service
member after he or she has completed Section IV.
4. Submit the original copy of VA Form 21-4502 and itemized invoice to the VA
regional office shown in Item 23, Section III, Attention: Financial Division. The
itemized invoice should include the following:
• The net cost of any approved adaptive equipment and installation charges. If
certain items of approved adaptive equipment (automatic transmission,
power seats, etc.) are included in the purchase price, also submit a copy of
the window sticker.
• A list of which adaptive equipment is standard on the vehicle or other
conveyance.
• The unpaid balance due on the vehicle which is to be paid by VA.
• A certification that the amounts billed do not exceed the usual and
customary cost for the purchase and installation of the adaptive equipment.

PAGE 3

ADAPTIVE EQUIPMENT FOR AUTOMOBILES AND SIMILAR VEHICLES
IMPORTANT
Adaptive equipment for the operation of the vehicle cannot be provided if the veteran or service member is blind, requires a driver because of
physical disability, or does not have a valid State driver's license or learner's permit. The list below shows the equipment that is authorized for
the qualifying disabilities shown in Section II of VA Form 21-4502. Request approval from the nearest VA health care facility for any
equipment not shown below, or if adaptive equipment is required for driver training and testing.

A. BASIC EQUIPMENT
DISABILITY

ADAPTIVE EQUIPMENT

Loss of a foot (including loss of use)...............................

Basic automatic transmission and power brakes

Loss of both feet (including loss of use)..........................

Basic automatic transmission, power steering and power
brakes.

Loss of a hand (including loss of use).............................
Loss of a hand and a foot (including loss of use)............

Basic automatic transmission and power steering.
Basic automatic transmission, power steering and
power brakes.

B. ADDITIONAL EQUIPMENT - SINGLE DISABILITIES
LOSS OF LEFT FOOT (INCLUDING LOSS OF USE)

LOSS OF RIGHT FOOT (INCLUDING LOSS OF USE)

1. Hand-operated dimmer switch

1. Left foot-operated gas pedal.

2. Hand-operated parking brake

2. Hand-operated dimmer switch.

3. If standard transmission selected, bar welded to clutch pedal
to prevent foot slipping down or off to side.

3. Hand-operated parking brake.

4. Relocation of control switched, as needed.

4. Extension on brake pedal from left foot operation if
not part of car.
5. If standard transmission selected, bar welded to clutch pedal
so both clutch and brake pedals may be operated with the
left foot.

C. ADDITIONAL EQUIPMENT - MULTIPLE DISABILITIES
LOSS OF BOTH FEET (INCLUDING LOSS OF USE)
1. Hand-operated brake and gas pedal in combination.
2. Hand-operated parking brake.
3. Hand-operated dimmer switch.

LOSS OF BOTH HANDS, TRIPLE OR QUADRUPLE
EXTREMITY LOSS (INCLUDING LOSS OF USE)
Any combination of hand/foot control which does not
involve steering, and relocation of control switches or levers as
required.

4. Steering wheel knob or ring.
5. Two-way power seat.

VA FORM 21-4502, XXX XXXX

PAGE 4