Va Form 21 8678 PDF Details

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QuestionAnswer
Form Name Va Form 21 8678
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names va form10 8678, 10 8678, va form 10 8678 for 2019, va form 10 8678 fillable

Form Preview Example

OMB Approved No. 2900-0198

Respondent Burden: 10 Minutes

APPLICATION FOR ANNUAL CLOTHING ALLOWANCE

(UNDER 38 U.S.C. 1162)

PRIVACY 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, 58VA21/22, Compensation, Pension, Education, and Rehabilitation Records - VA, published in the Federal Register. Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: VA may not conduct or sponsor, and 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 existing 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 1-800-827-1000 for mailing information on where to send your comments.

IMPORTANT: Please read the instructions below carefully, before completing the form.

1. FIRST NAME, MIDDLE NAME, LAST NAME OF VETERAN

2.VA FILE NUMBER

3.SOCIAL SECURITY NO.

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 THE APPLIANCE OR MEDICATION

6.TYPE OF APPLIANCE OR NAME OF MEDICATION (Artificial leg, metal brace, wheelchair, etc.)

7.LOCATION OF VA MEDICAL CENTER WHICH ISSUED THE APPLIANCE OR MEDICATION

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 appliance, described above, because of my service-connected disability or that I use a medication for my service-connected skin condition that causes irreparable damage to my outer clothing.

8. SIGNATURE OF VETERAN

9. DATE

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, or for the fraudulent acceptance of any payment to which you are not entitled.

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 qualify for annual payment, eligibility must be established as of August 1 of the year for which payment is claimed.

WHAT APPLIANCES ARE INCLUDED? Appliances such as an artificial limb, rigid extremity brace, rigid spinal or cervical brace, wheelchair, crutches or other appliance prescribed for the claimant’s service-connected disability. Soft and flexible devices, such as an elastic stocking are not included.

WHAT MEDICATIONS ARE INCLUDED? Any medication, prescribed by a physician for a service-connected skin condition, that causes permanent stains or otherwise damages the veteran’s clothing.

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.

VA FORM

21-8678

SUPERSEDES VA FORM 21-8678, AUG 2002,

MAY 2003

WHICH WILL NOT BE USED.

 

 

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Step 2: As you launch the file editor, you will see the document ready to be filled out. Apart from filling out various blank fields, you may as well do other things with the form, namely adding your own text, modifying the original text, adding images, putting your signature on the document, and much more.

Pay attention while completing this form. Make sure all mandatory fields are done properly.

1. Firstly, when filling in the va form 10 8678 pdf, start in the section containing subsequent blanks:

Filling in segment 1 of va form 10 8678 fillable

2. After the first array of fields is done, go to type in the suitable information in these - SIGNATURE OF VETERAN Sign in ink, DATE, VA FORM, JUNE, and Page of.

va form 10 8678 fillable conclusion process shown (step 2)

Lots of people frequently make mistakes when completing Page of in this section. Don't forget to read twice everything you type in here.

3. This next stage is usually straightforward - fill in all the blanks in Type of Appliance or Name of Skin, List of ServiceConnected, Month and Year Appliance or Skin, Name and location of VA facility, List all impacted locations Chest, APPROVED, Example A, Example B, Yes, Yes, Yes, Yes, Yes, Yes, and Yes to conclude this process.

Stage number 3 in filling out va form 10 8678 fillable

4. To go onward, the next form section requires filling in a few blank fields. Included in these are EXAMINATIONEVALUATION DATE If, NOTES, GENERATED BY, AUTHORIZED BY, VA FORM, JUNE, DATE, DATE, and Page of, which you'll find integral to continuing with this PDF.

A way to fill in va form 10 8678 fillable step 4

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