Fillable CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES (U.S. Department of Veterans Affairs)

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CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES (U.S. Department of Veterans Affairs)

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CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
OMB Approved No. 2900-0830
Respondent Burden: 5 minutes
Expiration Date: 07/31/2024
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 3. Use this form to
submit a request for reimbursement of travel expenses. For more information, contact us at https://iris.custhelp.va.gov, or call
us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.
VA forms are available at www.va.gov/vaforms. After completing the form, if returning by mail, mail to: Veteran Readiness and
Employment (VR&E) Intake Center, Department of Veterans Affairs, P.O. Box 5210, Janesville, WI 53547-5210.
VA FORM
JUL 2021
28-0968
Page 1
SECTION I: CLAIMANT'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable circle to help
expedite the processing of the form.
Enter International Phone Number (If applicable)
5. TELEPHONE NUMBER (Include Area Code)
I agree to receive electronic correspondence from VA in regards to my claim.
6. EMAIL ADDRESS (Optional)
SECTION II: AUTHORIZATION TO REPORT
11. TRAVEL AT GOVERNMENT'S EXPENSE
IS NOT AUTHORIZED
IS AUTHORIZED
1. CLAIMANT'S NAME (First, Middle Initial, Last)
3. DATE OF BIRTH (MM/DD/YYYY)
2. VA FILE NUMBER
ZIP Code
Country
State/Province
City Apt./Unit Number
4. CURRENT MAILING ADDRESS
(Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
7. REASON FOR REPORTING (Choose one)
Initial Evaluation Reevaluation Counseling Training Attendant Travel
8. NAME AND ADDRESS OF ISSUING OFFICE
City State
Issuing Office
Street Address
ZIP Code
9. REPORTING DATE (MM/DD/YYYY)
10. REMARKS (Indicate type of authorized travel, tickets, etc.)
12. AUTHORIZED PERIOD (MM/DD/YYYY)
13. AUTHORIZED MILEAGE RATE
.
$
SUPERSEDES VA FORM 20-0968, MAR 2018,
WHICH WILL NOT BE USED.
14. MEAL AND LODGING RATE
16. AUTHORITY 17. FISCAL SYMBOL
15. ESTIMATED COST TO TRAVEL
$
. .
$
38 CFR 21.370 TO 21.376
36X0137-3546
18. SIGNATURE OF AUTHORIZING OFFICIAL
SECTION III: VOUCHER FOR MILEAGE ALLOWANCE
(Claim for Reimbursement of Travel Expenses Mileage Allowance Basis)
22. MILES TRAVELED
(Round Trip)
23. AMOUNT CLAIMED AT
AUTHORIZED MILEAGE RATE
24. TOTAL MILEAGE ALLOWANCE
.
$
.
$
Page 2
25. I AM CLAIMING REIMBURSEMENT OF EXPENSES OTHER THAN MILEAGE, SUCH AS TOLLS, PARKING, LODGING, AND MEALS.
YES (If "Yes," complete Item 26)
NO
VA FORM 28-0968, JUL 2021
26. ITEMIZE EXPENSES BELOW AND PROVIDE A RECEIPT FOR EACH CLAIMED EXPENSE
A. PARKING
B. TOLLS
D. MEALS
C. LODGING
H. TOTAL AMOUNT CLAIMED (Items 26A-26G)
G. TOTAL AMOUNT CLAIMED (Items 26A-26F)
F. OTHER
E. OTHER
.
$
.
$
.
$
.
$
.
$
.
$
.
$
.
$
SECTION IV: STATEMENTS AND CERTIFICATIONS
CLAIMANT CERTIFICATION: I CERTIFY THAT I have incurred a cost for the travel claimed. I have not obtained transportation at
Government expense, or used a Government-owned conveyance, or Government purchased tickets/tokens, or received other transportation
resources at no cost to me. I am the only person claiming for the travel listed. I have not previously received payment for the transportation
claimed. I have filled this form out completely and that it is true and correct to the best of my knowledge and belief.
19. SUB VOUCHER NUMBER
20. TRAVEL FROM (ADDRESS)
21. TRAVEL TO (ADDRESS)
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Page 3
VA FORM 28-0968, JUL 2021
27. CLAIMANT SIGNATURE (REQUIRED)
AUTHORIZING OFFICIAL'S CERTIFICATION: I CERTIFY THAT the claimant named herein reported to this office or designated location for the
authorized rehabilitation services on the date(s) specified below.
31. AUTHORIZING OFFICIAL SIGNATURE
SECTION V: VOUCHER AUDIT OR REVIEW
36. REMARKS
PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be
false, or for fraudulent receipt of any document you are not entitled to.
PRIVACY ACT NOTICE: The responses you submit are considered confidential (38 U.S.C. 5701). Your obligation to respond is required in order to obtain benefits.
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 Veteran
Readiness and Employment Records - VA, published in the Federal Register. Information that you furnish may be utilized in computer matching programs with other
Federal or State agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of
your participation in any benefit program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: This form is used to submit a request for reimbursement of beneficiary travel expenses by a Chapter 31 claimant (38 U.S.C. 111). Title 38,
United States Code, allows VA to ask for this information. It should take you approximately 5 minutes to review the instructions, find the information, and complete this
form. VA cannot conduct or sponsor a collection of information unless a valid Office of Management and Budget (OMB) control number is displayed. You are not
required to respond to a collection of information if this number is not 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.
28. DATE SIGNED (MM/DD/YYYY)
29. DATE REPORTED (MM/DD/YYYY)
30. TITLE OF AUTHORIZING OFFICIAL
32. DATE SIGNED (MM/DD/YYYY)
33. AMOUNT DUE
.
$
34. DATE SIGNED (MM/DD/YYYY)
35. VOUCHER AUDITOR
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GUIDELINES FOR CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES AND ELIGIBILITY REQUIREMENTS
Page 4
VA FORM 28-0968, JUL 2021
A claimant who is applying for or receiving Veteran Readiness and Employment (VR&E) services may be reimbursed for travel
expenses if the travel meets one of the following conditions listed below:
1. The claimant is scheduled to report to a designated place for an initial evaluation, a reevaluation, or a counseling appointment
(including personal or vocational adjustment counseling) under the provisions of 38 CFR 21.376. Travel must be 50 miles or
over (one-way) of the commuting distance from the claimant's residence to the designated place of appointment.
2. The claimant is participating in a rehabilitation program or program of employment services and travel is required under the
provisions of 38 CFR 21.370. Travel must be within the jurisdiction of the Regional Office and must be approved by the
claimant's case manager.
3. The claimant is participating in a rehabilitation program or program of employment services and travel is required under the
provisions of 38 CFR 21.372. Travel must be outside the jurisdiction of the Regional Office and must be approved by the
claimant's case manager.
4. The claimant needs the services of an attendant to accompany him or her while traveling to his or her rehabilitation appointment
due to the severity of his or her disability condition under the provisions of 38 CFR 21.274.
NOTE: Travel reimbursement for a claimant's regular case management appointment cannot be authorized unless the claimant is
reporting for vocational exploration or vocational adjustment counseling.
INSTRUCTIONS FOR COMPLETING CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES
1. VR&E staff must use this form to certify that the claimant reported to the specified place of appointment.
2. The claimant or legal representative of the claimant must sign this form.
3. Claim for reimbursement of travel expenses on this form may be submitted personally or mailed to the VR&E office of
jurisdiction.
4. The calculation of mileage request for reimbursement is calculated to and from the claimant's residence and designated place of
appointment.
5. The actual cost of bus, train, taxi, or other public transportation fare may be reimbursed in lieu of mileage; however,
consideration must be given to the most economical means of transportation.
6. Receipts are required for allowable non-mileage expenses such as toll fees for bridge, road, and tunnel, parking, ferry fares, and
fares for bus, train, taxi or other public transportation meals, or lodging. Payment for meals and lodging may be paid if the travel
and actual meeting or training exceed 12 hours. Prior approval is required for meals and lodging.
7. The claimant must request his or her travel reimbursement to include submission of receipts within 30 days from the date of
completion of his or her travel. Claimant will forfeit travel benefits if claimant does not submit request for reimbursement within
the 30-day period.
8. Payment for the travel reimbursement will be sent directly to the claimant's bank account through the Electronic Fund Transfer
(EFT).
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CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES (U.S. Department of Veterans Affairs)

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Completed 6 July 2022

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