APPLICATION IN ACQUIRING SPECIALLY ADAPTED HOUSING OR
SPECIAL HOME ADAPTATION GRANT
(Title 38 U.S.C. Section 2101(a) or 2101(b))
OMB Approved No. 2900-0132
Respondent Burden: 10 minutes
Expiration Date: 6/30/2024
We need this information to determine or verify your eligibility for a specially adapted housing or special home adaptation grant. Title 38,
U.S.C. 2101(a) or 2101(b) allows us to ask for this information. We estimate that you will need an average of 10 minutes to review the instructions, find the
information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. 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.
This application should be submitted to the VA regional office where your claim file is located or this form can be
completed online by visiting www.ebenefits.va.gov.
1. FIRST NAME - MIDDLE INITIAL - LAST NAME 2. SOCIAL SECURITY NO. 3. VA FILE /CLAIM NUMBER
4. DATE OF BIRTH
(MM/DD/YYYY)
6. ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)
9. HAVE YOU MADE PREVIOUS APPLICATION FOR HOME IMPROVEMENT AND STRUCTURAL ALTERATION GRANT?
5. E-MAIL ADDRESS
(If "Yes," give name and address of facility)
(If "Yes," give date (MM/DD/YYYY) and place)
7. TELEPHONE NUMBERS OF APPLICANT (Include Area Code)
A. DAYTIME B. EVENING C. CELL
8. HAVE YOU MADE PREVIOUS APPLICATION FOR SPECIALLY ADAPTED HOUSING?
(If "Yes," give date (MM/DD/YYYY) and place)
10. ARE YOU CONFINED TO A NURSING HOME OR MEDICAL CARE FACILITY?
11. REMARKS
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.
12B. DATE SIGNED (MM/DD/YYYY)
CERTIFICATION
I am applying for assistance in acquiring specially adapted housing or special home adaptation grant because of the nature of my service-connected disability. I
understand that there are medical and economic features yet to be considered before I am eligible for this benefit, and that I will be notified of the action taken on this
application as soon as possible.
VA FORM
JUN 2021
26-4555
SUPERSEDES VA FORM 26-4555, SEP 2018,
WHICH WILL NOT BE USED.
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, CFR 1.576 for routine uses (for example: Authorizing release of information to Congress when requested for statistical purposes) identified in the VA
system of records, 55VA26, Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant Records,
and Vendee Loan Applicant 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, CFR 3.809. 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.
YES
NO
YES NO
YES NO
PRIVACY ACT NOTICE:
RESPONDENT BURDEN:
INSTRUCTIONS:
12A. SIGNATURE OF APPLICANT (Sign full name in ink.)
