21-4502
Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) (VA Form 21-4502)
VA Form 21-4502 is the U.S. Department of Veterans Affairs Application for Automobile or Other Conveyance and Adaptive Equipment, under 38 U.S.C. 3901-3904. VA's form page says to use it if you're a Veteran or service member with qualifying disabilities and want to apply for benefits to help pay for a vehicle that meets your needs. The page says the benefit can help buy a vehicle or other conveyance, like a motorhome, commercial truck or farm machine, and approved adaptive equipment.
The PDF has four pages. The Veteran or service member completes Sections I and II, VA completes Section III, the Certificate of Eligibility, and the Veteran or service member completes Section IV, the receipt, once the vehicle is delivered. Page 3 holds instructions for the Veteran and for the seller, and page 4 lists adaptive equipment by disability.
VA's page says you can apply online instead of filling out and sending the paper form. You can fill out the PDF free in your browser on this page and download the result without an account.
Items 1 to 8B: name, Social Security number, VA file number if any, date of birth, service number, phone, email with a consent to electronic correspondence, the current address and a service member's planned address after release.
Branch of service, active duty status, places and dates of entry and release, whether and when you applied for VA disability compensation, the VA office with your file, the type of conveyance, any earlier application, and the certification signed in Items 16 and 17.
Completed by VA. Boxes for loss or permanent loss of use of a foot or hand, permanent impairment of vision, severe burn injury and ALS, the authorization text, the VA office in Item 23 and the certifying official's signature.
Make, model and year, vehicle identification number, total purchase price, date of sale, whether you will operate the vehicle and hold a valid State driver's license or learner's permit, the seller's name and address, and the signature and date of receipt.
What the benefits are, what conveyance may be purchased, when to submit, instructions to the Veteran and to the seller, and the adaptive equipment authorized for each qualifying disability.
If completed by hand, the form asks for ink, neat and legible printing, one letter per box and each applicable check box completely filled in.
The signature in Item 16 is marked required, with the date in Item 17. The certification above it covers getting a license before operating the vehicle and any previous automobile grant.
Page 1 says to mail the completed form to the Evidence Intake Center in Janesville, Wisconsin. VA's page also says you can apply online.
The instructions say VA determines eligibility and, if eligibility exists, completes Section III and returns the form. The form says not to purchase a vehicle until authorized by VA.
When the vehicle and adaptive equipment arrive from the seller, complete Section IV and give the original VA Form 21-4502 to the seller.
Invoices for adaptive equipment or installation not on the seller's invoice go to the nearest VA health care facility, with your full name and VA file number and the itemized costs the form lists.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
Page 1 says to mail the completed form to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. The page 3 instructions also say to send the form to your nearest VA regional office.
VA's form page says you can apply online instead of filling out and sending the paper form.
The seller sends the original form and the itemized invoice to the VA regional office shown in Item 23, Section III, Attention: Financial Division.
The form points to Ask VA at https://ask.va.gov/ and the toll-free number 1-800-827-1000 (TTY: 711).
The August 2024 edition supersedes the July 2021 edition. It carries OMB Control No. 2900-0067, which expires 08/31/2027, and an estimated burden of 15 minutes.
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The form gives each section to a different person.
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The form says there is no time limit for filing a claim, but the claim has to be authorized by VA before the automobile or conveyance is purchased.
The form says VA is required by law to pay the benefit to the seller of the vehicle, and payment cannot be made to the Veteran or service member. It says the adaptive equipment benefit may be paid to either the seller or the Veteran or service member.
The form says the amount paid is limited by law and points to https://www.va.gov/disability/compensation-rates/special-benefit-allowance-rates/ for the current rate. It prints no amount.
Yes. VA's form page says you can apply online instead of filling out and sending the paper form.
The form says that effective January 5, 2023, claimants may receive an additional vehicle or conveyance if more than 30 years have elapsed since the most recent one. It also describes a second vehicle when the first was destroyed in a natural or other disaster, through no fault of the eligible person and without insurer compensation for the loss.
Page 4 lists the equipment authorized for each qualifying disability, such as a basic automatic transmission, power steering and power brakes. The form says VA approves all adaptive equipment as prescribed by a VHA provider before purchase, and equipment may be provided for no more than two vehicles in a four-year period.
