Fillable Printable VA Form 10-5392

VA Form 10-5392

INDIVIDUAL NAME

(Please print)

SIGNATURE

DATE(S) OF

SERVICE

HOURS

VA FORM

JUNE 2016

10-5392

VA SERVICE ASSIGNMENTORGANIZATION NAME

As an Occasional Volunteer, I agree, for an indefinite period, with the following statement: I hereby waive all claims to monetary benefits for services rendered as a volunteer worker on

a “without compensation” basis. I understand that this waiver applies only to remuneration (compensation) for specific services rendered in a VA Voluntary Service (VAVS) Program

and is not related to any other VA services or benefits to which I am entitled. (NOTE: VA has entered into this agreement by the authority of 38 U.S.C. 7405(a)(1)(D). This agreement

may be cancelled by either party upon written notice.

OCCASIONAL VOLUNTEER TIME SHEET