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, wheelchair, etc.) 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 A POWER OF ATTORNEY? (if "Yes", please identify name and/or Organization) 10A. SIGNATURE OF VETERAN YES NO VA FORM MAR 2006 10-8678 SUPERSEDES VA FORM 21-8678, MAY 2003, WHICH WILL NOT BE USED. Page 1 of 2 CERTIFICATION: I hereby apply for annual clothing allowance under 38 U.S.C. 1162. I certify that I wear or use a prosthetic or orthopedic applicance, described above, because of my service-connected disability or that I use a medication for my service-connected skin condition that causes irreparable damage by my outer clothing. 10B. DATE PENALTY - The law provides servere 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. SHADED FOR VA USE ONLY 11. CHECK OFF BOXES: STATIC NON-STATIC NOT ENTITLED 12. EXAMINATION/EVALUATION DATE (If applicable) 13A. PROCESSED BY: 13B. DATE 14A. AUTHORIZED/APPROVED BY: 14B. DATE 3. SOCIAL SECURITY NUMBER VA FORM MAR 2006 10-8678 SUPERSEDES VA FORM 21-8678, MAY 2003, WHICH WILL NOT BE USED. Page 2 of 2 INFORMATION AND INSTRUCTIONS COVERING APPLICATION FOR ANNUAL CLOTHING ALLOWANCE WHO IS ENTITLED TO AN ANNUAL CLOTHING ALLOWANCE? Veterans, who because of a service-connected disability, wear or use a prosthetic or orthopedic appliance (including a wheelchair) which tends to wear out or tear clothing, and veterans, who because of a service-connected skin condition use a medication that causes irreparable damage to outer garments, are eligible for payment of an annual clothing allowance. To qualifty for annual payment, eligibility must be established as of August 1 of the year for which payment is claimed. If you have not submitted a claim for disability compensation, VA Form 21-526 must be completed and sent to the VA Regional Office nearest your home. You can also apply for disability compensation on our website at http://www.vba.va.gov. WHERE TO FILE CLAIM? If you have previously submitted a claim for disability compensation, send your application to the Prosthetic and Sensory Aids Service (121), at your local VA Medical Center. If you have not made application for disability compensation, send the form to the VA regional office nearest your home. WHAT MEDICATIONS ARE INCLUED? Any medication, prescribed by a physician for a service-connected skin condition, that causes permanent stains or otherwise damages the veteran's clothing. WHAT APPLICANCES ARE INCLUDED? Appliances such as an artificial limb, rigid extremity brace, rigid spinal or cervical brace, wheelchair, crutches or other applicance prescribed for the claimant's service-connected disability. Soft and flexible devices, such as an elastic stocking are not included.