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

OMB Control No. 2900-0067
Respondent Burden: 15 Minutes
Expiration Date: XXXXXXX
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)
IMPORTANT: Read the "Information and Instructions" on Page 3 before completing this form. Also, read the Privacy Act
and Respondent Burden information below before completing the form.
SECTION I - APPLICATION
NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to help expedite processing of
the form.
1. VETERAN/SERVICEMEMBER'S NAME (First, Middle Initial, Last)

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

3. VA FILE NUMBER (If applicable)

2. SOCIAL SECURITY NUMBER

Month

5. VETERAN'S SERVICE NUMBER (If applicable) 6. TELEPHONE NUMBER (Include Area Code)

Day

Year

7. E-MAIL ADDRESS (Optional)

NOTE: A servicemember 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. SERVICEMEMBER'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

10. ARE YOU ON ACTIVE DUTY?

NAVY

AIR
FORCE

MARINE
CORPS

COAST
GUARD

OTHER

YES

(Specify)

11B. DATE OF ENTRY

11A. PLACE OF ENTRY INTO ACTIVE DUTY

Month

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

YES

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

Month

TRUCK

Year

Day

Day

Year

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

12B. DATE YOU APPLIED

NO

Day

11D. DATE OF RELEASE
Month

12A. HAVE YOU APPLIED FOR VA DISABILITY
COMPENSATION? (If "Yes,"give place)

NO

Year

OTHER
(Specify)

15. HAVE YOU PREVIOUSLY APPLIED FOR AN AUTOMOBILE OR OTHER CONVEYANCE? (This is a once-per-lifetime grant)
YES

Month

NO

Day

Year

Place

(If "Yes,"give date and place)
I hereby apply for the conveyance checked in Item 9 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.
18. TELEPHONE NUMBERS (Include Area Code)
16. SIGNATURE OF VETERAN OR SERVICEMEMBER 17. DATE SIGNED
(Sign in ink)
A. DAYTIME
Month

VA FORM
XXXX

21-4502

Day

Year

EXISTING STOCKS OF VA FORM 21-4502, FEB 2015,
WHICH WILL BE USED.

B. EVENING

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VETERAN/SERVICEMEMBER'S SOCIAL SECURITY NO.

SECTION III - CERTIFICATE OF ELIGIBILITY (To be completed by VA)
QUALIFYING DISABILITIES (Check appropriate box(es))
19A. LOSS OF FOOT
RIGHT

LEFT

19B. LOSS OF HAND
BOTH

RIGHT

LEFT

19C. PERMANENT LOSS OF USE OF FOOT 19D. PERMANENT LOSS OF USE OF HAND
BOTH

RIGHT

20. PERMANENT IMPAIRMENT OF VISION

LEFT

BOTH

YES

LEFT

BOTH

22. AMYOTROPHIC LATERAL SCLEROSIS
(ALS)

21. SEVERE BURN INJURY

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

RIGHT

NO

YES

NO

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

23. 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 9, 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 doesn't 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.
I CERTIFY THAT the veteran has not previously received an allowance for automobile or other conveyance under 38 U.S.C. 3901-3904.
24. NAME AND LOCATION OF VA OFFICE

25A. SIGNATURE OF CERTIFYING OFFICIAL (Sign in ink)

25B. DATE SIGNED

TTLE OF CERTIFYING OFFICIAL

SECTION IV - RECEIPT FOR AUTOMOBILE OR OTHER CONVEYANCE AND ADAPTIVE EQUIPMENT (To be completed by veteran or servicemember)
26. MAKE AND MODEL
28. VEHICLE IDENTIFICATION NO. (VIN)

27. YEAR
29. TOTAL PURCHASE PRICE

30. DATE OF SALE

$
31A. I WILL OPERATE THIS VEHICLE
YES

NO

32. NAME OF SELLER

31B. I HAVE A VALID STATE DRIVER'S LICENSE OR LEARNER'S PERMIT
YES

NO

33. ADDRESS OF SELLER

I hereby acknowledge receipt of the automobile or other conveyance with the adaptive equipment specified on attached invoice.
34A. SIGNATURE OF VETERAN OR SERVICEMEMBER (Sign in ink)

34B. DATE OF RECEIPT

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.

VA FORM 21-4502, XXXX

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INFORMATION AND INSTRUCTIONS
If you have questions about this form, how to fill it out, or about benefits, call VA toll-free at 1-800-827-1000
(If you use a Telecommunications Device for the Deaf (TDD), the federal relay number is 711.)
You may also contact VA by Internet at https://iris.va.gov
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. This payment is a once-per-lifetime grant, and the amount paid is limited
by law. Contact VA for the current rate.
A veteran or servicemember 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: Do not purchase a vehicle until authorized by VA. VA is required by
law to pay the benefit to the seller of the vehicle. Payment cannot be made to the
veteran or servicemember.
2. Adaptive equipment
A veteran or servicemember who qualifies for the vehicle allowance also qualifies
for adaptive equipment unless he or she is blind, requires a driver, or doesn't have
a valid State driver's license or learner's permit. See the attached list 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 more than once, and it may be paid to
either the seller or the veteran or servicemember.
3. Special drivers training for disabled veterans should contact the nearest VA
health care facility to request this training.
B. What conveyance may be purchased?
You may purchase a new or used automobile, truck, station wagon, or certain
other types of conveyance if approved by VA.

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 servicemember
1. Complete all items of Section I in duplicate and submit both copies to VA. If
you have previously applied for disability compensation, send the form to the VA
regional office where your claims folder is located. If you have not applied for
disability compensation or have not separated from military service, send the form
to the nearest VA regional office.
2. VA will determine your eligibility and, if eligibility exists, VA will complete
Section II and return the form to you.
3. Purchase a vehicle. When you receive the vehicle and the adaptive equipment
from the seller, complete Section III.
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.
E. Instructions to seller
1. Make sure that Section II of VA Form 21-4502 is completed and signed by VA.
2. Deliver the vehicle, including VA-approved adaptive equipment provided and/
or installed by the seller.
3. Obtain the original copy of VA Form 21-4502 from the veteran or
servicemember after he or she has completed Section III.
4. Submit the original copy of VA Form 21-4502 and itemized invoice to the VA
regional office shown in Section II, Attention: Financial Division, for payment.
The itemized invoice must 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 combined
with other items.
• 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.

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 Vocational Rehabilitation 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: We need this information in order to determine eligibility for automobile or other conveyance and adaptive equipment allowance (38 U.S.C. Chapter 39). Title 38,
United States Code, allows us to ask for this information if this number is not displayed. We estimate that you will need an average of 15 minutes to review the instructions, find the information,
and complete the form. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.

VA FORM 21-4502, XXXX

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ADAPTIVE EQUIPMENT FOR AUTOMOBILES AND SIMILAR VEHICLES
IMPORTANT
Adaptive equipment for the operation of the vehicle cannot be provided if the veteran or servicemember 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.
Basic automatic transmission and power steering.
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)............

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.

LOSS OF LEFT HAND (INCLUDING LOSS OF USE)
1. Steering wheel knob or ring.
2. Right-hand operated direction signals.
3. Right-hand or foot-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.
LOSS OF RIGHT HAND (INCLUDING LOSS OF USE)
1. Steering wheel knob or ring.
2. Left hand-or foot-operated parking brake.
3. Relocation of control switches, as needed.
4. Left hand gear shift lever.

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, XXXX

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