Fillable Printable VA Form 1107

VA Form 1107

REQUEST FOR REPAIRS, AND/OR ACCESSORIES

INSTRUCTIONS

WHEN REPAIRS ARE NEEDED

1. Please complete items 1 through 8 and check appropriate box in Section I - Repairs that best explains your reason for returning the device for

repairs.

2. Wrap device (including transmitter, receiver, cords, tubing, etc.) in a protective foam blanket or some other protective product and place in a

postal pouch with this form and mail too: Department of Veterans Affairs, Denver Distribution Center, P.O. Box 25166, Denver, CO 80225-0166.

DO NOT SEND earmold, presentatin case, eyeglass fronts, etc.

WHEN ACCESSORIES ARE NEEDED FOR THIS DEVICE

1. Please complete items 1 through 8 and Section II - Accessories. Indicate item(s) needed, cords, rubing, wax guards, earhooks, etc. Please indicate

length when ordering cords or straight tubing.

2. Place defective items (cords or tubing if necessary) in a postal pouch along with this form and mail too: Department of Veterans Affairs, Denver

Distribution Center, P.O. Box 25166, Denver, CO 80225-0166.

1. LAST NAME, FIRST NAME, MIDDLE INITIAL

2. DATE OF BIRTH (MM/DD/YYYY) 3. LAST FOUR DIGITS OF YOUR

SOCIAL SECURITY NO.

4. DATE MAILED (MM/DD/YYYY)

5. HOME MAILING ADDRESS

DEVICE INFORMATION

6. MAKE 7. MODEL

8. SERIAL NUMBER(S)

SECTION I - REPAIRS

1. DESCRIPTION OF DEFECTS (Check appropriate box(es))

DEAD FADES INTERMITTENT MOISTURE DAMAGE TELE COIL DEAD/WEAK

NOISY WEAK DISTORTED EXCESSIVE BATTERY DRAIN FEEDBACK

SECTION II - ACCESSORIES

1. ITEM(S) NEEDED

2. REMARKS

VA FORM

JUN 1998 (RS)

1107

(Electronic version)