Form VA Form 28-1905r VA Form 28-1905r Receipt of Supplies (Chapter 31 - Veteran Readiness and

OMB Approved No. 2900-XXXX
Respondent Burden: 10 minutes
Expiration Date: XX/XX/XXXX
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

RECEIPT OF SUPPLIES
(Chapter 31 - Veteran Readiness and Employment)

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Claimants must use this form
to verify receipt of the supplies and/or equipment requested on VAF 28-1905m and approved by the Department of Veterans Affairs. 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 completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, and
completely fill in each applicable circle to help expedite processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)

2. VA FILE NUMBER

3. ADDRESS TO WHERE SUPPLIES AND EQUIPMENT WERE DELIVERED TO CLAIMANT (Number and street or rural route, P.O. Box, City, State,
ZIP Code and Country)

Apt./Unit Number

City
Country

State/Province

ZIP Code

SECTION II: CLAIMANT'S VERIFICATION OF RECEIPT OF SUPPLIES AND/OR EQUIPMENT
Instructions: This form is used to verify the claimant's receipt of the supplies and/or equipment requested on VAF 28-1905m on
and approved by the VA. The claimant must certify receipt of supplies by completing the requested information, signing, and dating the appropriate data fields
below.

WAS ITEM
RECEIVED?

NAME OF ITEM AND DESCRIPTION (Specifications, Size, etc.)

QUANTITY (Set,
Pair, etc.)

DATE OF RECEIPT

Yes
No

Yes
No
Yes
No
Yes
No
Yes
No

Yes
No

Yes
No

VA FORM
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28-1905r

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WAS ITEM
RECEIVED?

NAME OF ITEM AND DESCRIPTION (Specifications, Size, etc.)

QUANTITY (Set,
Pair, etc.)

DATE OF RECEIPT

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

COMMENTS ON ANY DAMAGED ITEM LISTED ABOVE (Use this space to comment on any item that was damaged upon receipt. If the item was not accepted
due to the damage, please indicate this. If more space is needed, additional pages may be attached).

SECTION III: CERTIFICATION AND SIGNATURE

I CERTIFY THAT I have filled this form out completely and that it is true and correct to the best of my knowledge and belief.
4A. CLAIMANT'S SIGNATURE (REQUIRED)

4B. DATE SIGNED (MM/DD/YYYY)

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 by the claimant to verify receipt of supplies and/or equipment provided by the VA (38 U.S.C. 3104). Title 38, United States Code, allows VA
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 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.

VA FORM
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28-1905r

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