Va 26-4555 Veteran's Application In Acquiring Specially Adapted Hou

OMB Approved No. 2900-0132
Respondent Burden: 10 minutes
Expiration Date: 6/30/2024

Department of Veterans Affairs

Reference Number: 197356
VETERAN'S 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 response 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 1800-827-1000 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 OF VETERAN

2. VETERAN'S SOCIAL SECURITY NO.

BILL BCIEN

XXX-80-XXXX

4. DATE OF BIRTH

5. E-MAIL ADDRESS

07/01/1941

[email protected]

3. VA FILE /CLAIM NUMBER

6. ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)
88 Main Causeway
Somewhere, FL 92900

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

B. EVENING

C. CELL
(XXX)XXX-5309

8. HAVE YOU MADE A PREVIOUS APPLICATION FOR SPECIALLY ADAPTED HOUSING?(If "YES," give date and place)
Yes No
9. HAVE YOU MADE PREVIOUS APPLICATION FOR HOME IMPROVEMENT AND STRUCTURAL ALTERATION GRANT?(If "YES," give date and
place) Yes No
10.
Yes

ARE YOU CONFINED TO A NURSING HOME OR MEDICAL CARE FACILITY? (If "YES," give name and address of facility)
No

11.

REMARKS

Comments for test review

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 VETERAN (Sign full name)

12B. DATE SIGNED

Electronic Application - Validated by LGY (Signature not required)

02/29/2020

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
JUN 2021

26-4555

SUPERSEDES VA FORM 26-4555, SEP 2018,
WHICH WILL NOT BE USED.

Additional Information Provided in the Online Application
Location of Claim File:

ARMY
NAVY

Applicant's Branch of Service:
Service Serial Number(s):

Method of Separation of Service:

Retired

Enter Service Date:

10/01/2001

Enter Service Location:

Orlando FL

Active Duty:

No

Released From Active Duty Date:

09/30/2016

Injury Date:

10/12/2015

Applied for Disability Compensation:

Yes, Date: Location:  

Previously Applied for Specially Adapted Housing:

No

Previously Received Specially Adapted Housing Grant:

No

Does the Applicant Have a Power of Attorney? (If "YES," give name and address of facility)
Yes No

AIR FORCE
COAST GUARD

MARINE CORPS
OTHER