Form VA Form 10-8678 VA Form 10-8678 Application for Annual Clothing Allowance Under Title 38

OMB Approved No. 2900-0198
Estimated Burden:10 Minutes
Exp. Date: XX/XX/XXX

APPLICATION FOR ANNUAL CLOTHING ALLOWANCE
PRIVACY ACT INFORMATION: No benefits may be granted unless this form is completed fully as required by law (38 C.F.R. 3.810). Responses you submit are
considered confidential (38 U.S.C. 5701). They may be disclosed outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses
identified in the VA system of records, 24VA136 “Patient Medical Record - VA”, published in the Federal Register. Information submitted is subject to verification
through computer matching programs with other agencies.
RESPONDENT BURDEN: VA may not conduct or sponsor, and the 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 10 minutes 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 1-877-222-8387 for mailing information on where to send your
comments.

ELIGIBLITY / ENTITLEMENT FOR AN ANNUAL CLOTHING ALLOWANCE: A Veteran who wears or uses a prescribed
prosthetic, orthopedic appliance, and/or skin medication for a service connected disability may be eligible for an annual clothing
allowance. To be entitled, the prosthetic, orthopedic appliance must cause wear / tear; skin medication must cause irreparable staining to
your outergarments.
WHO IS ELIGIBLE FOR MORE THAN ONE ANNUAL CLOTHING ALLOWANCE? Effective December 16, 2011, Veterans
who wear or use more than one qualifying prescribed prosthetic or orthopedic appliance and/or prescription medication for more than
one service-connected disability or skin condition may be eligible for more than one clothing allowance. To be eligible for more than
one clothing allowance, the qualifying appliances must wear or tear more than one type of article of the Veteran's clothing and/or
medications must irreparably damage more than one type of the Veteran's clothing or outergarment.
WHAT TYPES OF CLOTHING ARE INCLUDED? Clothing such as shirts, blouses, pants, skirts, shorts and similar garments
permanently damaged by qualifying appliances and/or skin medications are considered in clothing allowance decisions. Shoes, hats,
scarves, underwear, socks, and similar garments are not included.
WHERE TO FILE A CLAIM? If you have previously submitted a claim for disability compensation, send this application (VA Form
10-8678) to the Prosthetic and Sensory Aids Service (121) at your local VA Medical Center. If you have not made an application for
disability compensation, complete VA Form 21-526 and send to the VBA regional office nearest your home.
INSTRUCTIONS: This application should be submitted to the Prosthetic and Sensory Aids Service at your nearest VA Medical Center
on or before August 1st of the benefit year for which you are applying. For example: If you are applying for the 2014 benefit, this
application should be received on or before August 1, 2014.
1. LAST NAME, FIRST NAME, MIDDLE NAME OF VETERAN

2. VETERAN'S SSN

3. MAILING ADDRESS OF VETERAN (No. and Street or Rural Route, City or P.O., State and Zip Code) If new address check box.

4. VETERAN'S DAYTIME TELEPHONE NUMBER (include area code)

4a. EVENING TELEPHONE NUMBER (include area code)

4b. VETERAN'S EMAIL ADDRESS

5. CALENDAR YEAR FOR APPLICATION

CERTIFICATION: I hereby apply for the annual clothing allowance benefit authorized under 38 USC §1162. In doing so I certify that because of my
service-connected disability or disabilities, I regularly (1) wear or use the prosthetic or orthopedic appliance(s) listed in section 7 which tends to wear
out or tear my clothing; or (2) use a skin medication(s) listed in section 7 which causes irreparable staining to my outergarments. Note: If I have
multiple prostheses, orthopedic appliances, or skin medications as listed in section 7, the combination of these items causes me to replace my
outergarments faster than if I used a single item.
ACKNOWLEDGEMENT: I acknowledge that by applying or receiving more than one clothing allowance benefit, an application for the annual
clothing allowance benefit requires a yearly submission to the nearest Prosthetic and Sensory Aids Office on or before August 1st of the calender year.
6. SIGNATURE OF VETERAN

VA FORM
JUNE 2015

10-8678

DATE

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7. Type of Appliance or Name of Skin
Medication (Artificial leg, metal brace,
wheelchair, etc.)

8. List of Service-Connected
Disability/Disabilities Requiring Use
of Appliance(s) or Skin Medication(s)

9. Month and
10. Name and location of VA facility that issued appliance or
Year Appliance
skin medication (if not a VA facility include facility's phone
or Skin
Medication was
number)
issued (MM/YYYY)

11. List all impacted
location(s)
(Chest, Back, Buttock, Left or
Right Leg, Left or Right Arm)

FOR VA USE
ONLY
APPROVED?

Example A

Yes

No

Example B

Yes

No

1.

Yes

No

2.

Yes

No

3.

Yes

No

4.

Yes

No

5.

Yes

No

PENALTY- The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false, or for the fraudulent
acceptance of any payment to which you are not entitled.
FOR VA USE ONLY
12. AMOUNT OF CLOTHING ALLOWANCES

# ELIGIBLE

# NOT ELIGIBLE

# UPPER Extremity (2 maximum)

# LOWER Extremity (2 maximum)

13. EXAMINATION/EVALUATION DATE (If applicable)

14. NOTES:

15. GENERATED BY:

DATE

16. AUTHORIZED BY:

DATE

VA FORM
JUNE 2015

10-8678

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