VA Form 21-4502: Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904)

Fill out VA Form 21-4502 online by answering plain-English questions. Claim Raven puts your answers on the official August 2024 edition of the form, and you download the filled PDF ready to sign. It is free with a Claim Raven account.

What VA Form 21-4502 is for

Use this form to apply for the automobile or other conveyance allowance and adaptive equipment. VA says to get approval before you buy the vehicle or adaptive equipment. You fill in Sections I and II now. VA completes Section III, and you complete Section IV only after the vehicle is delivered.

Need adaptive equipment only? For equipment-only assistance, VA directs you to Form 10-1394 and the prosthetic representative at your local VA medical center. Read VA's automobile and adaptive equipment guidance.

Parts someone else completes

Section III, the Certificate of Eligibility (Items 18 to 24), is completed by VA. Do not check a qualifying-disability box or sign as the certifying official. After approval and delivery, you give the original completed form to the seller, who sends it with an itemized invoice to the VA office shown in Item 23.

What you fill in by hand

The filler never asks for your Social Security number, VA file number, date of birth or signature. You write those in by hand. Leave these boxes for yourself:

  • Item 2: Social Security number (also at the top of page 2)
  • Item 3: VA file number
  • Item 4: date of birth
  • Item 5: service number
  • Item 6: international phone number
  • Items 16 and 17: signature and date signed
  • Section IV, Items 25 to 33: receipt for the vehicle

Where to send it

  • Online: start with the application linked from VA's Form 21-4502 page.
  • By mail: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
  • In person: the form's instructions also direct you to a VA regional office.
  • Do not buy the vehicle or equipment first. Wait for VA's approval, and contact your local VA Prosthetic and Sensory Aids Service before you obtain adaptive equipment.
  • After approval and delivery, give the original completed form to the seller, and keep a copy for yourself.

Claim Raven does not submit forms to VA. You review the filled PDF, sign and date it, and send it to VA yourself. Claim Raven is independent and is not affiliated with VA.

Official form and guide

This filler uses the August 2024 edition of the form.