VA Form 21-4502 Printable, Fillable in PDF

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VA Form 21-4502 Printable, Fillable in PDF – A VA Form 21-4502, also known as an Authorization for Automobile or Other Conveyance and Adaptive Equipment, is a form used by the Department of Veterans Affairs to authorize the use of an automobile or other conveyance and adaptive equipment. When a veteran wants to claim an allowance to acquire a car or any type of adapted equipment because of a medical handicap, they must utilize this form. There are three parts to this application. When completing the first step, the veteran will be required to indicate the sort of vehicle or adaptable equipment he or she is seeking, such as a car, van, truck, or other adaptive equipment. The Department will complete the second section, which will include specific information about the veteran’s disability that qualifies him or her for such an allowance. The final section of this form will be completed after the vehicle has been purchased, and it will include information such as the price, make, and model of the vehicle or equipment purchased, among others.

What Is A VA Form 21 4502 And How Does It Work?

VA Form 21-4502 is referred to as an Authorization for Automobile or Other Conveyance and Adaptive Equipment in the Veterans Administration (VA). The Department of Veterans Affairs in the United States uses this form to collect information from veterans. To claim an allowance to acquire a car or adapted equipment owing to a medical handicap, a veteran must complete and submit this form.

Application for an automobile or other mode of transportation and adaptive equipment will require information about the claimant and their medical disability, which will be included in the application. The first part will ask for the claimant’s personal information as well as details on the transportation service he or she is seeking. An example of this would be a new automobile, truck, or another kind of adapted equipment. The Department of Veterans Affairs will be responsible for completing Section II. This section will go through the claimant’s qualifying impairment in further depth. It will not be possible to finish the last portion unless the veteran has acquired a car. It will include specifics on the item, such as the price, the manufacturer, and the model.

According to the form, the kinds of equipment that are approved for each impairment are specified. It is your responsibility to get clearance from the local VA health care institution or regional office if you need adapted equipment that is not on the approved list.

Requirements for Eligibility
In the case of a vehicle grant
To apply for a one-time payment to assist you in the purchase of a vehicle that has been specifically outfitted, you must complete VA Form 21-4502. If the application is granted, the VA will make a direct payment to the vehicle’s seller.

In The Case Of Adaptive Equipment

You must complete VA Form 10-1394 to be considered for adapted equipment alone. If your application is granted, the VA may pay you or the equipment supplier directly. Vehicles with adaptive equipment include features such as a manual gearbox, power brakes, and seats, as well as power steering and parking brakes.

Requirements For Providing Evidence

This kind of impairment must be connected to your military service and contain at least one of the following symptoms to qualify for these VA benefits: loss or permanent loss of use of one or both feet; loss or permanent loss of use of one or both hands; loss or permanent loss of use of one or both feet a severe burn injury (deep partial thickness or full thickness burns resulting in scar formation that can cause contractures and limitations in the visual field in the better eye); permanent decreased vision in both eyes: 20/200 vision or less in your better eye with glasses, or central vision 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.

The Components Of A VA Form 21-4502 Are As Follows:

The following sections are contained within a VA Form 21-4502:

Identification Information for Veterans and Service Members
Information Regarding the Application
Certificate of Eligibility (Certificate of Eligibility)
Receipt for an automobile or other mode of transportation, as well as adaptive equipment

How To Submit An Application

To apply for benefits to assist you in the purchase of a vehicle that has been specially equipped, you must complete VA Form 21-4502. You will need to complete VA Form 10-1394 to be considered for an adaptive equipment grant. Before making the purchase, you must file a claim and receive approval from the insurance company.

Filling Out VA Form 21-4502 (Veterans Affairs)

You must provide the following information on VA Form 21-4502 to complete the form:

Veteran/Service Member Identification Information

Veteran’s/service member’s name
Social security number
VA file number
Social security number
Veteran’s service number
Telephone number
Email address
Current address
Service member’s planned address following release from active duty

Application Information

Branch of Service: Army, Navy, Air Force, Marine Corps, Coast Guard, other
Whether you are on active duty
Place of entry into active duty
Date of entry
Place of release from active duty
Date of release
Whether you applied for VA disability compensation
Date you applied
Location of VA office that has your file
Type of conveyance applied for
Whether you have previously applied for an automobile or other conveyance
Signature of veteran or servicemember
Date signed
Telephone numbers

Certificate of Eligibility

Qualifying disabilities
Loss or foot
Loss of hand
Permanent loss of use of foot
Permanent loss of use of hand
Permanent impairment of vision
Severe burn injury
Amyotrophic lateral sclerosis (ALS)
Certification that veteran has not previously received an allowance for automobile or other conveyance under 38 U.S.C. 3901-3904
Name and location of VA office
Signature and title of certifying official
Date signed

Receipt for Automobile or Other Conveyance and Adaptive Equipment

Make and model
Year
Vehicle identification number (VIN)
Total purchase price
Date of sale
Whether you will operate the vehicle
Whether you have a valid state driver’s license or learner’s permit
Name of seller
Address of seller
Signature of veteran or servicemember
Date of receipt