Instructions
Two short sets of steps: When repairs are needed, and When accessories are needed for this device.
VA1107
Request for Repairs, and/or Accessories
- Agency
- VA
- Revision
- October 2006
- Fillable fields
- 20
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form VA1107: Request for Repairs, and/or Accessories
VA Form VA1107 is the U.S. Department of Veterans Affairs Request for Repairs, and/or Accessories. It is the card that goes in the package with a device sent for repair, or with an order for accessories, to the Denver Acquisition & Logistics Center using its postage-free label.
The top section identifies the person and the device: name, date of birth, the last four digits of the Social Security number, the date mailed, the home mailing address and the device's make, model and serial number. Section I lists defects to check for a repair. Section II lists the items needed, such as cords, tubing, wax guards and ear hooks.
The instructions mention a reverse side, but the PDF on VA's page is one page. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form VA1107
Items 1 to 5: about you
Last name, first name and middle initial, date of birth, last four digits of the Social Security number, date mailed and home mailing address.
Items 6 to 8: device information
The device's make, model and serial number or numbers.
Section I: repairs
Check boxes for the defects: dead, fades, intermittent, moisture damage, tele coil dead or weak, noisy, weak, distorted, excessive battery drain and feedback.
Section II: accessories
A space for the items needed and a remarks area.
How to send VA Form VA1107
- 1
Fill in the top section
Complete Items 1 to 8 about yourself and the device, including the date mailed.
- 2
Complete Section I or Section II
Check the defects in Section I for a repair, or list the items needed in Section II for accessories, with lengths for cords or straight tubing.
- 3
Pack the device or parts
For a repair, the form says to send the complete device: transmitter, receiver, cords, tubing, etc. For accessories, include defective cords or tubing if necessary with the card.
- 4
Label and mail it
Attach the Denver Acquisition & Logistics Center postage-free label and deposit the package in U.S. Postal Service mail.
Why fill Form VA1107 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it
By mail
In the package, with the Denver Acquisition & Logistics Center postage-free label, through U.S. Postal Service mail. The form prints no street address.
No online version
VA's page offers the form as a downloadable PDF only.
Edition
The footer reads VA FORM OCT 2006 (RS) 1107, and VA's page gives a form revision date of October 2006.
Related forms
Who uses VA Form VA1107?
The instructions are written for the person sending the device or ordering accessories.
Official sources and the blank
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Questions about Form VA1107
What is VA Form VA1107 used for?
It goes with a device sent to the Denver Acquisition & Logistics Center for repair, or with a request for accessories for that device.
Where do I send VA Form VA1107?
The instructions say to attach the Denver Acquisition & Logistics Center postage-free label to the package and deposit it in U.S. Postal Service mail.
What do I include when sending a device for repair?
The form says to send the complete device: transmitter, receiver, cords, tubing, etc., with the form in the carton.
How do I order cords or tubing?
List them in Section II. The instructions ask for the length when ordering cords or straight tubing.
Does the form ask for my full Social Security number?
No. Item 3 asks for the last four digits of your Social Security number.