Fillable Printable VA Form Letter 10-426
Fillable Printable VA Form Letter 10-426
VA Form Letter 10-426
5. HOW MUCH LONGER DO YOU NEED THE ITEM(S)?
OMB NO. 2900-0188
Estimated Burden: I minute
Expiration Date: 11/30/2007
In Reply Refer To:
Dear
2 OR 3 TIM ES AS OFTEN AS NEEDEDNEVER
Our records indicate you have been furnished the following listed item(s) on loan:
1. HAVE/HAS THE ITEM(S) BEEN SATISFACTORY?
If you are still using the item(s), (it) (they) may be retained for your use for as long as you will need them. On the
other hand, if you no longer use or need the item(s), (it) (they) must be returned for possible use by another
veteran.
Please answer the questions below and return the letter to us. If you have any additional remarks or comments, use
the back of this letter.
Thank you for your cooperation.
YES
4. DO YOU STILL NEED THE ITEM(S)?
NO
YES
Sincerely,
DEPARTMENT OF VETERANS AFFAIRS
LONGER THAN 1 YEAR
DATE
FL 10-426
FEB 2005 (R)
NO (if ' ' No' ' , explain on reverse)
3. WHAT IS THE PRESENT CONDITION OF THE ITEM(S)?
NOT
USABLE
FAIR
GOOD EXCELLENT
1 YEAR6 MONTHS
6. IF YOU NO LONGER NEED THE ITEM(S), CAN YOU BRING OR SEND IT/THEM TO THE VA?
YES
NO (If ''No'', the VA will arrange to pickup the item(s) at your home.)
SIGNATURE OF VETERAN
(Complete only if you answered ' ' YES' ' to question 4.)
2. HOW OFTEN HAVE YOU USED IT/THEM?
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you
arenot required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all providers who must
complete this form will average 1 minute. This includes the time to read instructions, gather the necessary facts and fill out the form. This collection of information is
intended to identify prosthetic items which can be used by another individual and items that have exceeded their usefulness. Response to this letter is voluntary
andfailure to respond will have no adverse effect on benefits to which you might otherwise be entitled.
