Form VA Form 28-1905m VA Form 28-1905m Request for Supplies (Chapter 31-Vocational Rehabilitati

OMB Approved No. 2900-0061
Respondent Burden: 1 hour
Expiration Date: XX/XX/XXXX

REQUEST FOR AND RECEIPT OF SUPPLIES
(Chapter 31 - Vocational Rehabilitation)

PRIVACY ACT INFORMATION: No benefits may be paid unless a completed application form has been received (38 C.F.R. 21.212 and 21.224). The information
requested on this form is necessary to determine your entitlement to the benefit for which you have applied. The responses you submit are considered confidential, (38
U.S.C. 5701), formerly 3301. They may be disclosed outside the Department of Veterans Affairs (VA) only if the disclosure is authorized under the Privacy Act,
including the routine uses identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education and Vocational Rehabilitation Records - VA,
published in the Federal Register. The requested information is considered relevant and necessary to determine maximum benefits under the law. Information submitted
is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average one hour per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have comments
regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your comments.

SECTION A: TO BE SUBMITTED TO THE DEPARTMENT OF VETERANS AFFAIRS

FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

REHABILITATION GOAL

VA FILE NUMBER

ADDRESS TO WHICH SUPPLIES MAY BE DELIVERED TO VETERAN (Number and Street or Rural Route, City or P.O., State and Zip Code)

INSTRUCTIONS
REHABILITATION PROVIDER

REHABILITATION PROVIDER (Continued)

A. The Department of Veterans Affairs (VA) may furnish supplies to the
veteran named above, who is entering into or is already taking part in a VA
rehabilitation, independent living, or employment assistance program, if all of
the following conditions are met:
1. The facility/employer requires all persons being trained for or employed in
the same occupational or independent living goal to personally possess the
same books, tools, and other supplies; and
2. The veteran does not already possess the required items; and
3. The VA case manager has determined the supplies may be provided in
accordance with limitations and restrictions found in 38 U.S.C. and applicable
federal regulations.
B. VA will not furnish tools or other supplies which commonly are on hand for
use of all trainees or employees or which the veteran already owns.

C. If items are required under the conditions stated in A, and are not being
requested merely because the veteran desires them, request these supplies
by completing the section immediately following these instructions. You may
continue to list required items on another VA For 28-1905m. Additional pages
may be used if necessary.
D. In Section B, please sign and complete the Request and Certification of
Establishment section.

VETERAN
A. In Section B, the veteran's signature acknowledges that he or she does not
already possess the required items.
B. The veteran must complete Section C of this form and return it to the VA
case manager to report receipt of items.

SECTION B: REQUEST AND CERTIFICATION OF FACILITY OR ESTABLISHMENT
TYPE OF PROGRAM

On-Job Training

(√ )

Educational or Vocational Training

ITEM NO.
(If applicable)

Independent Living

Employment

Other (Specify)
ESTIMATED
COST

QUANTITY
(Set, pair, etc.)

NAME OF ARTICLE AND DESCRIPTION
(Catalog identification, size, etc.)

DATE

SIGNATURE AND TITLE OF OFFICIAL

NAME AND ADDRESS OF FACILITY OR ESTABLISHMENT (Number and street or rural route, city or P.O., state and Zip Code)
SIGNATURE OF VETERAN

VA FORM
APR 2014

28-1905m

DATE

SIGNATURE OF CASE MANAGER

SUPERSEDES VA FORM 28-1905M, NOV 2011,
WHICH WILL NOT BE USED.

DATE

SECTION C: RECEIPT OF SUPPLIES
CERTIFICATION OF VETERAN

TO THE DEPARTMENT OF VETERANS AFFAIRS (Veteran should check all that apply):
A. Any items that were requested in Section A but not received are listed below
B. Any items received in damaged or unacceptable condition are listed below.
C. I certify that all the supplies I received are in good condition.
WAS ITEM
RECEIVED?

NAME OF ARTICLE AND DESCRIPTION
(Catalog identification, size, etc.)

QUANTITY
(Set, pair, etc.)

DATE OF
RECEIPT

COMMENTS ON ITEM DAMAGED
OR UNACCEPTABLE

NOTE: Complete the certification of receipt of supplies by dating and signing the form below and returning it to your VA case manager.
SIGNATURE OF VETERAN

VA FORM 28-1905m, APR 2014

DATE