OMB Approved No. 2900-0198
Respondent Burdent:10 Minutes
APPLICATION FOR ANNUAL CLOTHING ALLOWANCE (Under 38 U.S.C. 1162)
PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION: No benefits may be granted unless this form is completed
fully as required by law (38 C.F.R. 3.810). Responses you submit are considered confidential (38 U.S.C. 5701). They may be disclosed
outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records,
24VA19“Patient Medical Record - VA”, published in the Federal Register. Information submitted is subject to verification thorough
computer matching programs with other agencies. This information is required to obtain or retain benefits. VA may not conduct or sponsor,
and the respondent is not required to respond to this collection of information unless it displays a valid OMB Control Number. Public
reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing
instructions, searching exiting data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. If you have comments regarding this burden estimate or any other aspect of this collection of information, call 1-877-222-8387
for mailing information on where to send your comments.
IMPORTANT: Please read the instructions below carefully, before completing the form.
If you have a VA Claim number and a SSN number, please provide both below.
1. FIRST NAME, MIDDLE NAME, LAST NAME OF VETERAN
2. VA CLAIM/FILE NUMBER
4. ADDRESS OF VETERAN (No. and street or rural route, city or P.O., State and Zip
Code). (If new address check box)
5. DISABILITY REQUIRING USE OF APPLIANCE OR MEDICATION.
6. TYPE OF APPLIANCE OR NAME OF MEDICATION (Artificial leg, metal brace,
7. NAME AND LOCATION OF VA MEDICAL CENTER OR OTHER
INSTITUTION WHICH ISSUED APPLIANCE OR MEDICATION
8. MONTH AND YEAR YOU WERE ISSUED APPLIANCE OR MEDICATION
9. DO YOU HAVE