26-4555 Application in Acquiring Specially Adapted Housing or Sp

OMB Approved No. 2900-0132
Respondent Burden: 10 minutes
Expiration Date: XXXXXXXX

APPLICATION IN ACQUIRING SPECIALLY ADAPTED HOUSING OR
SPECIAL HOME ADAPTATION GRANT
(Title 38 U.S.C. Section 2101(a) or 2101(b))
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
Title 38, CFR 1.576 for routine uses (for example: Authorizing release of information to Congress when requested for statistical purposes) identified in the VA system
of records, 55VA26, Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant Records, and
Vendee Loan Applicant Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN
account information is mandatory. Applicants are required to provide their SSN under Title 38, CFR 3.809. The VA will not deny an individual benefits for refusing to
provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.
RESPONDENT BURDEN: We need this information to determine or verify your eligibility for a specially adapted housing or special home adaptation grant. Title 38,
U.S.C. 2101(a) or 2101(b) allows us to ask for this information. We estimate that you will need an average of 10 minutes to review the instructions, find the
information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. Valid OMB control
numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to
send comments or suggestions about this form.

INSTRUCTIONS: This application should be submitted to the VA regional office where your claim file is located or this form can be
completed online by visiting www.ebenefits.va.gov.
1. FIRST NAME - MIDDLE INITIAL - LAST NAME

2. SOCIAL SECURITY NO.

4. DATE OF BIRTH

5. E-MAIL ADDRESS

3. VA FILE /CLAIM NUMBER

6. ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

7. TELEPHONE NUMBERS OF APPLICANT (Include Area Code)
A. DAYTIME

B. EVENING

C. CELL

8. HAVE YOU MADE PREVIOUS APPLICATION FOR SPECIALLY ADAPTED HOUSING?
YES

NO

(If "Yes," give date and place)

9. HAVE YOU MADE PREVIOUS APPLICATION FOR HOME IMPROVEMENT AND STRUCTURAL ALTERATION GRANT?
NO

YES

(If "Yes," give date and place)

10. ARE YOU CONFINED TO A NURSING HOME OR MEDICAL CARE FACILITY?
YES

NO

(If "Yes," give name and address of facility)

11. REMARKS

CERTIFICATION

I am applying for assistance in acquiring specially adapted housing or special home adaptation grant because of the nature of my service-connected disability. I
understand that there are medical and economic features yet to be considered before I am eligible for this benefit, and that I will be notified of the action taken on this
application as soon as possible.
12A. SIGNATURE OF APPLICANT (Sign full name in ink.)

12B. DATE SIGNED

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.
VA FORM
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26-4555

SUPERSEDES VA FORM 26-4555, FEB 2012,
WHICH WILL NOT BE USED.