VA Form 1107
REQUEST FOR REPAIRS, AND/OR ACCESSORIES
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
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
6. MAKE7. MODEL
8. SERIAL NUMBER(S)
SECTION I - REPAIRS
1. DESCRIPTION OF DEFECTS (Check appropriate box(es))
DEADFADESINTERMITTENTMOISTURE DAMAGETELE COIL DEAD/WEAK
NOISYWEAKDISTORTEDEXCESSIVE BATTERY DRAINFEEDBACK
SECTION II - ACCESSORIES
1. ITEM(S) NEEDED
JUN 1998 (RS)