VA FORM 28-0968 Claim for Reimbursement of Travel Expenses

OMB Approved No. 2900-0830
Respondent Burden: 15 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

CLAIM FOR VETERAN READINESS AND EMPLOYMENT
TRAVEL EXPENSES

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 3. Use this form to
submit a request for reimbursement of travel expenses. For more information, contact us at https://ask.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 complete each applicable check
box to help expedite the processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)
2. VA FILE NUMBER
3. CURRENT MAILING ADDRESS (If applicable) (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

4. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number (If applicable)
5. EMAIL ADDRESS (Optional)

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

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

Training

Attendant Travel

7. NAME AND ADDRESS OF ISSUING VR&E OFFICE
Issuing VR&E Office
Street Address
City
State/Province

ZIP Code/Postal Code

8. REPORTING DATE FOR SCHEDULED APPOINTMENT(MM/DD/YYYY)
9. REMARKS (Indicate Type of authorized travel, tickets, etc.)

10. TRAVEL AT GOVERNMENT'S EXPENSE
IS AUTHORIZED
IS NOT AUTHORIZED
VA FORM
XXX XXXX

28-0968

11. AUTHORIZED PERIOD (MM/DD/YYYY)

12. AUTHORIZED MILEAGE RATE

FROM

.

.

cents per mile

TO
SUPERSEDES VA FORM 28-0968, JUL 2022,
WHICH WILL NOT BE USED.

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SECTION II: AUTHORIZATION TO REPORT (CONTINUED)
13. MEAL AND LODGING RATE

14. ESTIMATED COST TO TRAVEL

.

$

.

$

15. AUTHORITY

16. FISCAL SYMBOL

38 CFR 21.370 TO 21.376

36X0137-3546

17. SIGNATURE OF AUTHORIZING OFFICIAL (CASE MANAGER)

SECTION III: VOUCHER FOR MILEAGE ALLOWANCE
(Claim for Reimbursement of Travel Expenses Mileage Allowance Basis)
18. TRAVEL FROM (ADDRESS)

19. TRAVEL TO (ADDRESS)

20. MILES TRAVELED (Round Trip)

21. AMOUNT CLAIMED AT AUTHORIZED MILEAGE RATE

22. TOTAL MILEAGE ALLOWANCE

$

$

.

.

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

NO

24. 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 24A-24F)

$

.

$

.

25. TOTAL AMOUNT CLAIMED (Items 22-24G)

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.
26. CLAIMANT SIGNATURE (REQUIRED)

VA FORM 28-0968, XXX XXXX

27. DATE SIGNED (MM/DD/YYYY)

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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.
28. REPORTING DATE FOR SCHEDULED APPOINTMENT

(MM/DD/YYYY)

29. TITLE OF AUTHORIZING OFFICIAL (CASE MANAGER)

31. DATE SIGNED (MM/DD/YYYY)

30. AUTHORIZING OFFICIAL SIGNATURE

VOUCHER AUDIT OR REVIEW
32. AMOUNT DUE
$

33. DATE SIGNED (MM/DD/YYYY)

34. VOUCHER AUDITOR

.

35. 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 INFORMATION: 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
Veteran Readiness 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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 2900-0830, and it expires XX/XX/20XX. Public reporting burden for this collection
of information is estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB
Control No. 2900-0830 in any correspondence. Do not send your completed VA Form 28-0968 to this email address.
VA FORM 28-0968, XXX XXXX

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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 requires 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 21.154.
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. Please refer to GSA to find the current
per diem rates for lodging and meals at http://www.gsa.gov/perdiem.
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
30-day period.
8. Payment for the travel reimbursement will be sent directly to the claimant's bank account through the Electronic Fund Transfer (EFT).

VA FORM 28-0968, XXX XXXX

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