Fillable Printable Veteran/Beneficiary Claim for Reimbursement of Travel Expenses

Veteran/Beneficiary Claim for Reimbursement of Travel Expenses

10-3542

NOV 2013

VA FORM

VETERAN/BENEFICIARY CLAIM FOR

REIMBURSEMENT OF TRAVEL EXPENSES

OMB Number: 2900-0798

Estimated Burden: 15 minutes

1.b Claimant's SSN

1.a Name of Person Claiming Travel Reimbursement (Last, First, Middle)

1.c Claimant's Date of Birth (mm/dd/yyyy)

3.b Veteran's SSN

3.a Name of Veteran (Last, First, Middle)

3.c Veteran's Date of Birth (mm/dd/yyyy)

2.a Claimant's status: (check one) Complete 3.a, 3.b, 3.c and 3.d if Caregiver, Attendant or Donor is checked.

Veteran

Caregiver

(National Caregiver Program)

Section A. Traveler's Information

Section B. Trip Information

1.a I am claiming travel reimbursement from address: (Street, City, State, Zip)

1.b Date Trip Began

(mm/dd/yyyy)

1.c Travel by:

(e.g., car, train, bus,

taxi)

2.c Travel by:

(e.g., car, train, bus,

taxi)

2.b Date Trip Ended

(mm/dd/yyyy)

2.a I am claiming return travel reimbursement to the address in B.1.a above

YES NO (if no, provide the Street, City, State, Zip below)

3. I am claiming reimbursement of expenses other than mileage, such as tolls, parking, lodging, meals.

(If yes, itemize expenses below and provide a receipt for each expense claimed. Use reverse if additional space is required)

YES NO

4. Treating Facility Name (VA or Non-VA location)

Penalty Statement: There are severe criminal and civil penalties including fine or imprisonment, or both, for knowingly submitting a false, fictitious, or fraudulent

claim

Certification: I have incurred a cost in relation to the travel claimed. I have not obtained transportation at Government expense, through the use of Government

owned conveyance, or Government purchased tickets/tokens, or received other transportation resources at no-cost to me. I am the only person claiming for the

travel listed. I have not previously received payment for the transportation claimed. I certify that the above information is correct.

Signature of Claimant

Date (mm/dd/yyyy)

Section C. Statements and Certifications

Attendant

(Medically authorized by VA)

Donor

(VA Transplant Care)

Other

5. Treating Facility Address (Optional)

10-3542

NOV 2013

VA FORM

Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections

111 to determine your eligibility for Beneficiary Travel benefits and will be used for that purpose. Information you

supply may be verified through a computer-matching program. VA may disclose the information that you put on

the form as permitted by law; possible disclosures include those described in the “routine use" identified in the

VA systems of records 24VA19 Patient Medical Record-VA, published in the Federal Register in accordance

with the Privacy Act of 1974. Providing the requested information is voluntary, but if any or all of the requested

information is not provided, it may delay or result in denial of your request for benefits. Failure to furnish the

information will not have any effect on any other benefits to which you may be entitled. If you provide VA your

Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to

identify Veterans and persons claiming or receiving VA benefits and their records, and for other purposes

authorized or required by law.

The Paperwork Reduction Act of 1995 requires VA to notify you that this information collection is in

accordance with the clearance requirements of Section 3507 of this Act. We anticipate the time expended by

individuals who must complete this form will average 3 minutes. This includes the time it will take to read

instructions, gather the necessary facts and fill out the form. No person will be penalized for failing to furnish

this information if it does not display a currently valid OMB control number. This information is collected under

38 CFR 70 and is intended to fulfill the need for Veterans and beneficiaries to claim Beneficiary Travel benefits

and for VA to determine the individual's eligibility for the benefit.

INSTRUCTIONS FOR COMPLETING

VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES

Who is Eligible for Reimbursement of Travel Expenses

1. Veterans rated by VA 30% or more service-connected for travel relating to any condition

2. Veterans rated by VA less than 30% for travel relating to their service-connected condition

3. Veterans receiving VA pension benefits for travel relating to any condition

4. Veterans with annual income below the maximum applicable annual rate of pension for any condition

5. Veterans who are unable to defray the cost of travel (as defined in current Beneficiary Travel regulations)

6. Veterans traveling in relation to a Compensation and Pension (C&P) examination

7. Certain Veterans in certain emergency situations

8. Beneficiaries of other Federal Agencies when authorized by that agency

9. Allied beneficiaries when authorized by appropriate foreign government agency

10. Certain non-Veterans when related to care of a Veteran (Caregivers under the National Caregivers

Program, medically required attendants, VA transplant care donor and support person, or other claimants

subject to current regulatory guidelines)

Instructions

1. The claimant or legal representative of claimant may complete this form.

2. Allied beneficiaries and beneficiaries of other federal agencies are not required to complete Section A,

Question 3a-c.

3. The form may be presented in person or mailed to VA health care facility where care was provided.

Addresses of VA health care facilities can be found at: http://www.va.gov/directory Note: The claim for

travel benefits may also be done in person at a VA health care facility.

4. Application for travel reimbursement must be done within 30 days of travel. Exception: application

beyond 30 days may occur when claim is a result of change in Beneficiary Travel eligibility.

5. Receipts are required for allowable non-mileage expenses, e.g., bridge, road and tunnel tolls; parking;

ferry fares; meals; lodging; and transport by bus, train, taxi or other public transportation. Prior approval

is required for meals and lodging.

6. Application will be evaluated to determine eligibility for travel benefits and services received. If eligible, the

claim will be processed for payment at currently authorized rate subject to any required deductibles.

7. Payment will be by electronic funds transfer (EFT) unless other arrangements have been made.

8. For assistance in completing the form, call 1-877-222-VETS (8387)