Questions and answers
Page 1 explains who determines eligibility and entitlement, which vehicles are considered, who receives a payment or a reimbursement, where payment amounts are listed, what documentation is needed and where to submit.
10-1394
Application for Adaptive Equipment—Motor Vehicle
- Agency
- VA
- Revision
- June 2024
- Fillable fields
- 41
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-1394: Application for Adaptive Equipment, Motor Vehicle
VA Form 10-1394 is the U.S. Department of Veterans Affairs Application for Adaptive Equipment, Automobile or Other Conveyance, listed under VHA on VA's form page as Application for Adaptive Equipment, Motor Vehicle. In its certification the applicant applies for adaptive equipment for the automobiles or other conveyances listed in Item 7, required for a service-connected disability. It covers payment to a registered provider, reimbursement to the eligible person, or both.
The two pages start with questions and answers on eligibility, entitlement, vehicles, payments and documentation. Part I is completed by the Veteran or Servicemember, Part II by VHA and Part III by VBA. The form says to complete all items of Part I and submit it to the Prosthetic and Sensory Aids Services at the nearest VA Medical Center.
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What's on VA Form 10-1394
Items 1 to 6: applicant
Name, SSN, mailing address and telephone number of the Veteran or Servicemember, then yes or no questions on a valid driver's license or permit and a VA Certificate of Eligibility.
Item 7: vehicles
For each vehicle: type, whether it was purchased with a VA automobile allowance, year, make, model, vehicle identification number and the date adaptive equipment was provided, which the form says to complete for repairs, replacement or reinstallations.
Certification, penalty and signature
The applicant's certification on payments, reimbursements and documentation, the penalty statement, and the signature and date in Items 8 and 9.
Part II: VHA entitlement
Items 10 to 22: documentation received and date, whether payment and reimbursement are approved, amounts requested and to be paid or reimbursed, the registered provider to pay, approving office, VHA station code, signature and date.
Part III: VBA processing
An authorization under 38 U.S.C. 3901-3904, a certification on payment limitations, and Items 23 to 26 for the authorizing office, VBA regional office code, signature and date.
How to file VA Form 10-1394
- 1
Read the questions and answers
Page 1 covers who determines eligibility and entitlement, the vehicles considered and the documentation for payments and reimbursements.
- 2
Complete all of Part I
The form says to complete all items of Part I: Items 1 to 6 on the applicant and Item 7 on each vehicle.
- 3
Gather the documentation
The form lists an itemized estimate and a final itemized invoice for payments. For reimbursements it lists an itemized estimate and a final itemized invoice, paid receipt or bill of sale, or for an unregistered provider a final itemized invoice, paid receipt or bill of sale.
- 4
Sign and date it
Read the certification and penalty statement, then sign Item 8 and enter the date in Item 9 as MM/DD/YYYY.
- 5
Submit it at a VA Medical Center
The form says to submit it to the Prosthetic and Sensory Aids Services at the nearest VA Medical Center. VHA completes Part II and VBA completes Part III.
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Where to send it and getting help
Where to submit
Prosthetic and Sensory Aids Services at your nearest VA Medical Center, as the form says.
Payment and reimbursement amounts
The form prints no amounts. It says the VA Adaptive Equipment Schedule for Automobile and Other Conveyance can be found at www.prosthetics.va.gov, and the certification says reimbursements will not exceed the amounts listed there.
Questions about a vehicle
The form says to contact your local VHA Drivers Rehabilitation Specialist or Prosthetic Representative if you are unsure whether a vehicle can receive the appropriate adaptive equipment.
Copy of VA Form 21-4502
The form says a copy is available at your local VBA Regional Office or by registering and logging on at https://www.ebenefits.va.gov/ebenefits/homepage.
Edition
The footer reads VA FORM 10-1394, JUN 2024. It carries OMB Control No. 2900-0188, which expires 06/30/2027, with an estimated burden of 15 minutes.
Related forms
21-4502
Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) (VA Form 21-4502)
90 fields, 4 pages
10-0103
Veterans Application for Assistance in Acquiring Home Improvements and Structural Alterations
12 fields, 1 page
10-10EZ
Instructions and Enrollment Application for Health Benefits
122 fields, 6 pages
Who uses VA Form 10-1394?
The form says who completes each part and who receives payments.
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Questions about Form 10-1394
What is VA Form 10-1394 used for?
It is the application for adaptive equipment for an automobile or other conveyance. In the certification the applicant applies for adaptive equipment for the vehicles in Item 7 required for a service-connected disability.
Which part does the Veteran or Servicemember fill in?
Part I, Items 1 to 9. The form says Part II is completed by VHA and Part III by VBA.
Where do I submit VA Form 10-1394?
The form says to complete all items of Part I and submit it to the Prosthetic and Sensory Aids Services at your nearest VA Medical Center.
What does the driver's license question mean?
Item 5 asks whether you have a valid driver's license or permit in possession. Next to the No box the form says: If no, only entitled to ingress / egress equipment.
Who receives the money?
The form says payments go only to a registered provider, and reimbursements go to the eligible Veteran or Servicemember.
Does the form list payment amounts?
No. It points to the VA Adaptive Equipment Schedule for Automobile and Other Conveyance at www.prosthetics.va.gov.
What is VA Form 21-4502?
Item 6 calls it the VA Certificate of Eligibility. The form says VBA reviews and certifies whether a Veteran or Servicemember meets the criteria, and an eligible person receives a certified form 21-4502.