Form VA Form 10-3542 VA Form 10-3542 Veteran/Beneficiary Claim for Reimbursement of Travel Ex

OMB Control No: 2900-0798
Estimated Burden: 10 minutes
Expiration Date: XX/XX/20XX

VETERAN/BENEFICIARY CLAIM FOR
REIMBURSEMENT OF TRAVEL EXPENSES

Section A. Traveler's Information
1.a Name of Person Claiming Travel Reimbursement (Last, First, Middle)

1.b Claimant's SSN

1.c Claimant's Date of Birth (mm/dd/yyyy)

2.a Claimant's status: (check one) Complete 3.a, 3.b, 3.c and 3.d if Caregiver, Attendant or Donor is checked.
Veteran

Caregiver
(National Caregiver Program)

Attendant
(Medically authorized by VA)

Donor
(VA Transplant Care)

3.a Name of Veteran (Last, First, Middle)

Other

3.b Veteran's SSN

3.c Veteran's Date of Birth (mm/dd/yyyy)

Section B. Trip Information
1.a I am claiming travel reimbursement from address:

(Street, City, State, Zip)

2.a I am claiming return travel reimbursement to the address in B.1.a above
YES

NO (if no, provide the Street, City, State, Zip below)

3. I am claiming reimbursement of expenses other than mileage, such as tolls, parking, lodging, meals.

YES

1.b Date Trip Began
(mm/dd/yyyy)

1.c Travel by:
(e.g., car, train, bus,
taxi)

2.b Date Trip Ended
(mm/dd/yyyy)

2.c Travel by:
(e.g., car, train, bus,
taxi)

NO

(If yes, itemize expenses below and provide a receipt for each expense claimed. Use reverse if additional space is required)
a.
b.
c.
d.
e.
f.
g.
h.
4. Treating Facility Name (VA or Non-VA location)

5. Treating Facility Address (Optional)

Section C. Statements and Certifications
Penalty Statement: There are severe criminal and civil penalties including fine or imprisonment, or both, for knowingly submitting a false, fictitious, or fraudulent
claim
Certification: I have incurred a cost in relation to the travel claimed. I have not obtained transportation at Government expense, through the use of 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 certify that the above information is correct.
Signature of Claimant

VA FORM
AUG 2024

10-3542

Date (mm/dd/yyyy)

INSTRUCTIONS FOR COMPLETING
VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES
Who is Eligible for Reimbursement of Travel Expenses
1. Veterans rated by VA 30% or more service-connected for travel relating to any condition
2. Veterans rated by VA less than 30% for travel relating to their service-connected condition
3. Veterans receiving VA pension benefits for travel relating to any condition
4. Veterans with annual income below the maximum applicable annual rate of pension for any condition
5. Veterans who are unable to defray the cost of travel (as defined in current Beneficiary Travel regulations)
6. Veterans traveling in relation to a Compensation and Pension (C&P) examination
7. Certain Veterans in certain emergency situations
8. Beneficiaries of other Federal Agencies when authorized by that agency
9. Allied beneficiaries when authorized by appropriate foreign government agency
10. Certain non-Veterans when related to care of a Veteran (Caregivers under the National Caregivers
Program, medically required attendants, VA transplant care donor and support person, or other claimants
subject to current regulatory guidelines)
Instructions
1. The claimant or legal representative of claimant may complete this form or apply for reimbursement online
at https://eauth.va.gov/accessva.
2. Allied beneficiaries and beneficiaries of other federal agencies are not required to complete Section A,
Question 3a-c.
3. This form may be submitted in person or mailed to the VA health care facility where care was provided.
Addresses of VA health care facilities can be found at: http://www.va.gov/directory.
4. Application for travel reimbursement must be submitted online, in person, or postmarked within 30
calendar days of travel completion. Exception: Application submission beyond 30 days may occur when
claim is a result of change in Beneficiary Travel eligibility.
5. Receipts are required for allowable non-mileage expenses, for example, bridge, road and tunnel tolls;
parking; ferry fares; meals; lodging; and transport by bus, train, taxi, or other public transportation. Prior
approval is required for meals and lodging.
6. Verification of attendance. Claims for expenses of travel to or from VA-authorized appointments with nonVA providers in the community are required to be submitted with documentation providing proof that
care/services were received from the community provider. Examples of valid proof include, but are not
limited to, work/school release note from the community provider, document on community provider
letterhead showing date appointment was completed, etc.
7. Applications determined eligible for travel benefits will be processed for payment at the current authorized
rate, subject to any applicable deductibles.
8. Payment will be made by electronic funds transfer (EFT) unless other arrangements have been made.
9. For assistance in completing the form, call 1-877-222-VETS (8387).
VA Burden Statement: 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 2900-0798, and it expires on
XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 10 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 Clearances Officer at [email protected].
Please refer to OMB Control No. 2900-0798 in any correspondence. Do not send your completed VA Form 10-3542 to this email
address.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Section 111 to determine your
eligibility for Beneficiary Travel benefits, and the information collected will be used for that purpose. Information you supply may be
verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by law; possible
disclosures include those described in the “routine use" identified in the VA systems of records 24VA19 Patient Medical Record-VA,
published in the Federal Register in accordance with the Privacy Act of 1974. Providing the requested information is voluntary, but if any
or all of the requested information is not provided, it may delay or result in denial of your request for benefits. Failure to furnish the
information will not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number,
VA will use it to administer your VA benefits. VA may also use this information to identify Veterans and persons claiming or receiving VA
benefits and their records, and for other purposes authorized or required by law.
VA FORM
AUG 2024

10-3542