Fillable Printable VA Form 10-0103
Fillable Printable VA Form 10-0103
VA Form 10-0103
CERTIFICATION
6. WHAT TYPE OF IMPROVEMENTS, ALTERATIONS, MODIFICATIONS ARE YOU APPLYING FOR:
SECTION I - VETERAN/SERVICEMEMBER APPLICATION (To be completed by Veteran or Servicemember)
VETERANS APPLICATION FOR ASSISTANCE
In Acquiring Home Improvements and Structural Alterations
VA FORM
JUN 2015
INSTRUCTIONS: SUBMIT THIS APPLICATION TO THE PROSTHETIC AND SENSORY AIDS SERVICE TO
THE NEAREST VA MEDICAL CENTER
3. APPLICANT'S ADDRESS
(Number and Street or Rural Route, City or P.O., State and ZIP Code)
HAVE YOU APPLIED OR RECEIVED HOME IMPROVEMENTS AND STRUCTURAL ALTERATIONS (HISA) IN THE PAST?
OMB Approval No. 2900-0188
Estimated Burden: Avg. 5 min.
2. APPLICANT'S SOCIAL SECURITY NO.
4. TELEPHONE NUMBER OF APPLICANT (Include Area Code)
1. NAME OF APPLICANT (LAST NAME, FIRST NAME, MI)
If "Yes" give
I am applying for assistance in acquiring Home Improvements and Structural Alterations.
9. SIGNATURE OF APPLICANT (Sign Full Name)
10. DATE SIGNED (mm/dd/yyyy)
* I understand that there are medical and economic determinations yet to be considered before I am eligible for this benefit, and that I will soon be notified
of the action taken on this application.
* I understand that cost limitations for improvements and structural alternations apply in the aggregate as a one lifetime benefit. Entitlements to this benefit
terminates when the cost limit is reached. Limitations cannot be exceeded either for one project or for any accumulation of projects.
* When the anticipated total cost of a necessary or appropriate home improvements or structural alterations exceeds the remaining balance of my allowable
benefit, I agree to pay the difference or the benefit will not be authorized.
* I acknowledge that the VA assumes no responsibility for maintenance, repair or replacement of requested improvements, alterations or installations;
assumes no product liability for, and extends no warranties, expressed or implied, including merchantability, as to equipment or devices installed; and
assumes no liability for damage caused by such equipment or devices or for their removal.
* I understand that this benefit can only be used within each of the several States, Territories, and Possessions of the United States, the District of Columbia,
and the Commonwealth of Puerto Rico.
* If approved for HISA benefits, are you requesting advance payment of HISA benefits? (VA may make an advance payment to the beneficiary
equal to 50 percent of the total benefit authorized for the improvement of structural alteration).
(MM/YYYY)
10-0103
Page 1 of 2
The law provides severe penalties including fine or imprisonment , or both, for willful submission
of any false statement or evidence of material fact.
5. E-MAIL ADDRESS OF APPLICANT
(1) DATE AND ADDRESS OF PROPERTY
TYPE OF IMPROVEMENTS, ALTERATIONS, MODIFICATIONS
HAVE YOU APPLIED OR RECIEVED OTHER VA HOUSING BENEFITS (I.E., SPECIALLY ADAPTED HOUSING, SPECIAL HOME ADAPTATION GRANT, OR VOCATIONAL
REHABILITATION AND EMPLOYMENT'S INDEPENDENT LIVING)?
If "Yes" give
(1) DATE
TYPE OF IMPROVEMENTS, ALTERATIONS, MODIFICATIONS
FOR NON-HOME OWNERS - A NOTORIZED STATEMENT FROM THE OWNER OF THE PROPERTY AUTHORIZING THE IMPROVEMENT OR
STRUCTURAL ALTERATION TO THE PROPERTY
A COLORED PHOTOGRAPH OF THE UNIMPROVED AREA
A WRITTEN ITEMIZED ESTIMATE OF COSTS FOR LABOR, MATERIALS, PERMITS, AND INSPECTIONS FOR THE HOME IMPROVEMENT AND
STRUCTURAL ALTERATION
8. IN ORDER TO COMPLETE THE HISA APPLICATION ATTACH THE FOLLOWING TO THIS APPLICATION:
(MM/YYYY)
AND ADDRESS OF PROPERTY
7. NAME OF PERSON OR COMPANY WITH WHOM I SATISFACTORILY REQUEST FOR NECESSARY LABOR AND MATERIALS
(Attach a signed copy of estimate which includes plans and specification
for work to be done by a licensed, bonded, and/or insured contractor).
YESNO
YESNO
YES NO
(Letter of approval will state this amount, subject to
amendment for inclusion of acceptable costs omitted in this application or found to be unnecessary.)
VETERANS APPLICATION FOR ASSISTANCE IN ACQUIRING HOME
IMPROVEMENTS AND STRUCTURAL ALTERATIONS, CONTINUED
SECTION II - (FOR VA USE ONLY) HISA COMMITTEE ACTION
TO ASSURE THE CONTINUATION OF TREATMENT OF APPLICANT'S DISABILITY (Specify the disability for which the home improvement
or structural alteration is necessary or appropriate)
TO PROVIDE ACCESS TO THE HOME OR TO ESSENTIAL LAVATORY AND SANITARY FACILITIES FOR TREATMENT OF:
HOME IMPROVEMENTS AND STRUCTURAL ALTERATIONS IS NECESSARY:
COST LIMITATION
A SERVICE-CONNECTED DISABILITY
A NONSERVICE-CONNECTED DISABILITY OF A VETERAN WITH SERVICE CONNECTED DISABILITIES RATED 50%OR MORE
TOTAL REMAINING $
AMOUNT APPROVED $
TOTAL LIFETIME BENEFIT: $
TOTAL PAID TO DATE $
ASSISTANCE IN THE AMOUNT OF $
APPLICATION DISAPPROVED
REMARKS:
DATE (mm/dd/yyyy)
SIGNATURE OF APPROVING OFFICIAL
(HISA COMMITTEE CHAIRMAN, PROSTHETIC REPRESENTATIVE, CHIEF of PROSTHETICS)
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VA FORM
JUN 2015
ADVANCE PAYMENT IN THE AMOUNT OF $
FINAL PAYMENT IN THE AMOUNT OF $
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all
individuals who must complete this form will average 5 minutes. This includes the time it will take to read instructions, gather the
necessary facts and fill out the form.
PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C.,
"Veterans Benefits, and will be used to determine your eligibility/entitlement and reimbursement of individual claims for home
improvement and structural alterations, and identify your medical records. Additional information may be solicited during the course
of processing your application. The information you supply may also be disclosed outside the VA as permitted by law or as stated in
the "Notices of Systems of VA Records' 24VA136, published in the Federal Register. Disclosure is voluntary, however, failure to
furnish the information will result in our inability to process your request promptly and serve your medical needs. Failure to furnish
the information will have no adverse effect on any other benefits to which you may be entitled.
PAID ON (MM/DD/YYYY)
(MM/DD/YYYY)PAID ON
APPROVED.
