Supplementary Statement for 2900-0067

Supplemental Stmt 2900-0067 (21-4502).docx

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

Supplementary Statement for 2900-0067

OMB: 2900-0067

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Supplemental Statement for VA Form 21-4502, Application for Automobile or Other Conveyance and Adaptive Equipment:


During a review of the #2900-0067 ICR (Reference # 201408-2900-015), submitted to OMB on 10/15/2014 (expiring 1/31/2015), it was found that the version of VA Form 21-4502, was the wrong form file in the request.  To correct this oversight, VBA is requesting that the ICR be opened for amendment. 


Also, due to RIN 2900-AP26, Automobile or Other Conveyance and Adaptive Equipment Certificate of Eligibility for Veterans or Members of the Armed Forces with ALS Due to Military Service, an interim final rule, it was noted that a new checkbox was needed to be added to the form, so ALS could be considered an eligible disability for auto allowance. Please note, RIN 2900-AP26, has not been submitted to OMB as yet, but will in the next couple of weeks. See Item 17 on the form for reference.  The explanation for the additional item is explained in Item 15 of the supporting statement.   


If possible, VBA is requesting that OMB review ICR #2900-0067 only after RIN 2900-AP26 is approved.  That way the form change is due to the regulation change.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorDepartment of Veterans Affairs
File Modified0000-00-00
File Created2021-01-27

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