Form VAF 28-0968 VAF 28-0968 Claim for Reimbursement of Travel Expenses

OMB Approved No. 2900-XXXX
Respondent Burden: 5 minutes
Expiration Date: XX/XX/XXXX
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this form to
submit a request for reimbursement of travel expenses. For more information, contact us at https://iris.custhelp.va.gov, or call us
toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA
forms are available at www.va.gov/vaforms. After completing the form, if returning by mail, mail to: Veteran Readiness and
Employment (VR&E) Intake Center, Department of Veterans Affairs, P.O. Box 5210, Janesville, WI, 53547-5210.
SECTION I: CLAIMANT'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable circle to help
expedite the processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)

2. VA FILE NUMBER

3. DATE OF BIRTH (MM/DD/YYYY)

4. CURRENT MAILING ADDRESS (If applicable) (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

Apt./Unit Number
State/Province

City
Country

ZIP Code

5. TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)

6. EMAIL ADDRESS (Optional)

I agree to receive electronic correspondence from VA in regards to my claim.

SECTION II: AUTHORIZATION TO REPORT
7. REASON FOR REPORTING (Choose item)
Initial Evaluation

Reevaluation

Counseling

Training

Attendant Travel

8. NAME AND ADDRESS OF ISSUING OFFICE
Issuing Office
Street Address
City

State

ZIP Code

9. REPORTING DATE (MM/DD/YYYY)

10. REMARKS (Indicate Type of authorized travel, tickets, etc.)

11. TRAVEL AT GOVERNMENT'S EXPENSE

12. AUTHORIZED PERIOD (MM/DD/YYYY)

13. AUTHORIZED MILEAGE RATE

IS AUTHORIZED

$

.

IS NOT AUTHORIZED

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SUPERSEDES VA FORM 28-0968, MAR 2015,
WHICH WILL NOT BE USED.

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14. MEAL AND LODGING RATE

.

$

15. ESTIMATED COST TO TRAVEL 16. AUTHORITY

.

$

17. FISCAL SYMBOL

38 CFR 21.370 TO 21.376

36X0137-3546

18. SIGNATURE OF AUTHORIZING OFFICIAL

SECTION III: VOUCHER FOR MILEAGE ALLOWANCE
(Claim for Reimbursement of Travel Expenses Mileage Allowance Basis)
19. SUB VOUCHER NUMBER

20. TRAVEL FROM (ADDRESS)

21. TRAVEL TO (ADDRESS)

22. MILES TRAVELED
(Round Trip)

23. AMOUNT CLAIMED AT
AUTHORIZED MILEAGE RATE
$

24. TOTAL MILEAGE ALLOWANCE

.

$

.

25. I AM CLAIMING REIMBURSEMENT OF EXPENSES OTHER THAN MILEAGE, SUCH AS TOLLS, PARKING, LODGING, AND MEALS.
YES (If Yes, complete Item 26).

NO

26. ITEMIZE EXPENSES BELOW AND PROVIDE A RECEIPT FOR EACH CLAIMED EXPENSE
A. PARKING

$

.

B. TOLLS

$

.

C. LODGING

$

.

D. MEALS

$

.

E. OTHER

$

.

F. OTHER

$

.

G. TOTAL AMOUNT CLAIMED (Items 26A-26F)

$

.

H. TOTAL AMOUNT CLAIMED (Items 26A-26G)

$

.

STATEMENTS AND CERTIFICATIONS
CLAIMANT CERTIFICATION: I CERTIFY THAT I have incurred a cost for the travel claimed. I have not obtained transportation at Government
expense, or used a Government-owned conveyance, or Government purchased tickets/tokens, or received other transportation resources at no cost to
me. I am the only person claiming for the travel listed. I have not previously received payment for the transportation claimed. I have filled this form out
completely and that it is true and correct to the best of my knowledge and belief.
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27. CLAIMANT SIGNATURE (REQUIRED)

28. DATE SIGNED (MM/DD/YYYY)

AUTHORIZING OFFICIAL'S CERTIFICATION: I CERTIFY THAT the claimant named herein reported to this office or designated location for the
authorized rehabilitation services on the date(s) specified below.
29. DATE REPORTED (MM/DD/YYYY)

30. TITLE OF AUTHORIZING OFFICIAL

31. AUTHORIZING OFFICIAL SIGNATURE

32. DATE SIGNED (MM/DD/YYYY)

VOUCHER AUDIT OR REVIEW
33. AMOUNT DUE

34. DATE SIGNED (MM/DD/YYYY)

35. VOUCHER AUDITOR

.

$
36. REMARKS

PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be
false, or for fraudulent receipt of any document you are not entitled to.
PRIVACY ACT NOTICE: The responses you submit are considered confidential (38 U.S.C. 5701). Your obligation to respond is required in order to obtain benefits.
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, Code of Federal
Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money
owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification
of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational
Rehabilitation and Employment Records - VA, published in the Federal Register. Information that you furnish may be utilized in computer matching programs with other
Federal or State agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of
your participation in any benefit program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: This form is used to submit a request for reimbursement of beneficiary travel expenses by a Chapter 31 claimant (38 U.S.C. 111). Title 38,
United States Code, allows VA to ask for this information. It should take you approximately 5 minutes to review the instructions, find the information, and complete this
form. VA cannot conduct or sponsor a collection of information unless a valid Office of Management and Budget (OMB) control number is displayed. You are not
required to respond to a collection of information if this number is not 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.
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GUIDELINES FOR CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES AND ELIGIBILITY REQUIREMENTS
A claimant who is applying for or receiving Veteran Readiness and Employment (VR&E) services may be reimbursed for travel
expenses if the travel meets one of the following conditions listed below:
1. The claimant is scheduled to report to a designated place for an initial evaluation, a reevaluation, or a counseling appointment
(including personal or vocational adjustment counseling) under the provisions of 38 CFR 21.376. Travel must be 50 miles or over
(one-way) of the commuting distance from the claimant's residence to the designated place of appointment.
2. The claimant is participating in a rehabilitation program or program of employment services and travel is required under the provisions
of 38 CFR 21.370. Travel must be within the jurisdiction of the Regional Office and must be approved by the claimant's case manager.
3. The claimant is participating in a rehabilitation program or program of employment services and travel is required under the provisions
of 38 CFR 21.372. Travel must be outside the jurisdiction of the Regional Office and must be approved by the claimant's case
manager.
4. The claimant needs the services of an attendant to accompany him or her while traveling to his or her rehabilitation appointment due
to the severity of his or her disability condition under the provisions of 38 CFR 21.274.
NOTE: Travel reimbursement for a claimant's regular case management appointment cannot be authorized unless the claimant is
reporting for vocational exploration or vocational adjustment counseling.

INSTRUCTIONS FOR COMPLETING CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES
1. VR&E staff must use this form to certify that the claimant reported to the specified place of appointment.
2. The claimant or legal representative of the claimant must sign this form.
3. Claim for reimbursement of travel expenses on this form may be submitted personally or mailed to the VR&E office of jurisdiction.
4. The calculation of mileage request for reimbursement is calculated to and from the claimant's residence and designated place of
appointment.
5. The actual cost of bus, train, taxi, or other public transportation fare may be reimbursed in lieu of mileage; however, consideration
must be given to the most economical means of transportation.
6. Receipts are required for allowable non-mileage expenses such as toll fees for bridge, road, and tunnel, parking, ferry fares, and fares
for bus, train, taxi or other public transportation meals, or lodging. Payment for meals and lodging may be paid if the travel and actual
meeting or training exceed 12 hours. Prior approval is required for meals and lodging.
7. The claimant must request his or her travel reimbursement to include submission of receipts within 30 days from the date of
completion of his or her travel. Claimant will forfeit travel benefits if claimant does not submit request for reimbursement within the 30day period.
8. Payment for the travel reimbursement will be sent directly to the claimant's bank account through the Electronic Fund Transfer (EFT).

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