10 1394 APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part I, entering your name, Social Security Number, and mailing address. Ensure all details are accurate for processing.
3. Provide your telephone number and indicate if you possess a valid driver's license. If yes, attach a copy.
4. List any service-connected disabilities that require adaptive equipment in the designated field.
5. In section 8, detail the vehicle(s) for which adaptive equipment is needed. Include type, year, make, model, and Vehicle Identification Number (VIN).
6. If applicable, indicate whether the vehicle was purchased with a VA automobile allowance and provide the date adaptive equipment was provided.
7. Complete Part II by having your Prosthetic Representative fill in authorized items and amounts for reimbursement.
8. Sign and date Part III after receiving services to certify satisfaction with the items provided.

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