Information Collection

Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) (21-4502)

IC 28212 under ICR 201404-2900-013 · OMB 2900-0067.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0067 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-4502 Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) (21-4502)	Form
VA Form 21-4502 Application for Automobile or other Conveyence & Adaptiv 21-4502(4-14).pdf www.va.gov/vaforms	Form

IC Title:

Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) (21-4502)

Agency IC Tracking Number:

2900-0067 VBA-COMP-NK

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.808

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-4502	Application for Automobile or other Conveyence & Adaptive Equipment	21-4502(4-14).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,552

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,552	0	1,552
Annual IC Time Burden (Hours)	388	0	388
Annual IC Cost Burden (Dollars)	9,312	9,312	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.