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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:
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.custhelp.com/
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 and II and submit to VA. Send the form to your
nearest VA regional office.
2. VA will determine your eligibility and, if eligibility exists, VA will complete
Section III and return the form to you.
3. Purchase a vehicle. When you receive the vehicle and the adaptive equipment
from the seller, complete Section IV.
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 III 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 IV.
4. Submit the original copy of VA Form 21-4502 and itemized invoice to the VA
regional office shown in Section III, Attention: Financial Division, for payment.
The itemized invoice must include the following:
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.
• 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.
• 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.
VA FORM 21-4502, MAR 2018
INFORMATION AND INSTRUCTIONS
