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VA Form 21-4502: Application for Automobile or Other Conveyance and Adaptive Equipment

VA Form 21-4502 is the application for the VA automobile allowance and adaptive equipment benefit, which helps veterans and service members with certain severe service-connected disabilities buy and equip a vehicle they can use.

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What is VA Form 21-4502?

VA Form 21-4502, Application for Automobile or Other Conveyance and Adaptive Equipment, is filed under 38 U.S.C. 3901-3904. The automobile allowance is a one-time payment toward the purchase of an automobile or other conveyance, which can also be a motorhome, commercial truck, or farm machine, for claimants with qualifying disabilities such as loss or permanent loss of use of a hand or foot, or qualifying vision impairment. Adaptive equipment, such as hand controls or lifts, can be approved separately and more than once.

The form collects the applicant's identifying information and disability basis, and includes certification sections that VA and the seller complete. VA pays the allowance directly to the seller of the vehicle, so approval should come before the purchase. The current edition is dated August 2024; the payable amount changes periodically, so check the current figure at va.gov.

Who files VA Form 21-4502?

Veterans with service-connected loss, or permanent loss of use, of one or both hands or feet
Veterans with qualifying service-connected vision impairment, severe burns, or ALS
Service members on active duty with a qualifying condition
Veterans who already received the allowance and now need adaptive equipment for another vehicle

How to fill out VA Form 21-4502

Complete the applicant section with your name, Social Security number, VA file number, and contact information.
Indicate whether you are applying for the automobile allowance, adaptive equipment, or both.
Sign and date the certification in the applicant section.
Submit the application to VA through va.gov or by mail to the address in the form instructions, and wait for VA to certify your eligibility.
After approval, take the certified form to the seller: VA pays the allowance directly to the seller, and adaptive equipment invoices are handled under VA's procedures.

Worth knowing: VA pays the automobile allowance directly to the seller, so apply and get VA certification before you buy the vehicle. The allowance amount changes periodically; check the current amount at va.gov.

Quick fill VA Form 21-4502 on this page

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Page 1 57 fields

Read Instructions above. SECTION 1. VETERAN / SERVICE MEMBER'S IDENTIFICATION INFORMATION. Read Note above. 1. VETERAN / SERVICEMEMBER'S

1. VETERAN / SERVICEMEMBER'S NAME. Enter Middle Initial. 1 character max.

1. VETERAN / SERVICEMEMBER'S NAME. Enter Last Name. 18 characters max.

2. Social Security Number. Enter last four digits.

2. Social Security Number. Enter middle two digits.

2. Social Security Number. Enter first three digits.

3. V. A. File Number (If applicable). Enter 9 digit file number.

4. Date of Birth. Enter 4 digit Year.

4. Date of Birth. Enter 2 digit Month.

4. Date of Birth. Enter 2 digit Day.

5. Veteran's Service Number (If applicable). Enter 9 digits.

6. Telephone Number. Enter last four digits.

6. Telephone Number. Enter second three digits.

6. Telephone Number (Include Area Code). Enter first three digits.

6. Enter International Phone Number (If applicable).

7. E-MAIL ADDRESS. 30 characters max.

7. I agree to receive electronic correspondence from V. A. in regards to my claim.

8. A. CURRENT ADDRESS. ZIP or Postal Code. Enter last 4 digits.

8. A. CURRENT ADDRESS. ZIP or Postal Code. Enter first 5 digits.

8. A. CURRENT ADDRESS. Enter Country. 2 characters max.

8. A. CURRENT ADDRESS. Enter State or Province. 2 characters max.

8. A. CURRENT ADDRESS. Enter City. 18 characters max.

8. A. CURRENT ADDRESS. Enter Apartment or Unit Number. 5 characters max.

NOTE: A service member planning early release should give both present military address and planned address following release from active

9. N O A. A.

12. A. Specify Name of Place.

13. LOCATION OF V. A. OFFICE THAT HAS YOUR FILE (If known).

11. A. PLACE OF ENTRY INTO ACTIVE DUTY.

11. C. PLACE OF RELEASE FROM ACTIVE DUTY (If applicable).

14. Specify OTHER TYPE OF CONVEYANCE.

15. Enter Place.

YES

12. A. NO.

14. Other (Specify).

YES

11. B. DATE OF ENTRY. Enter 4 digit Year.

11. D. DATE OF RELEASE. Enter 2 digit Day.

11. D. DATE OF RELEASE. Enter 2 digit Month.

11. D. DATE OF RELEASE. Enter 4 digit Year.

11. B. DATE OF ENTRY. Enter 2 digit Month.

11. B. DATE OF ENTRY. Enter 2 digit Day.

12. B. DATE YOU APPLIED. Enter 2 digit Day.

12. B. DATE YOU APPLIED. Enter 2 digit Month.

12. B. DATE YOU APPLIED. Enter 4 digit Year.

15. DATE. Enter 2 digit Day.

15. If "Yes," give date and place. DATE. Enter 2 digit Month.

15. DATE. Enter 4 digit Year.

17. DATE SIGNED. Enter 2 digit Day.

17. DATE SIGNED. Enter 2 digit Month.

17. DATE SIGNED. Enter 4 digit Year.

8. B. SERVICE MEMBER'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY (Number and Street or rural route, City or P.O., State and Zip

8. B. SERVICE MEMBER'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY. Enter Apartment or Unit Number. 5 characters max.

8. B. SERVICE MEMBER'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY. Enter City. 18 characters max.

8. B. SERVICE MEMBER'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY. Enter State or Province. 2 characters max.

8. B. SERVICE MEMBER'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY. Enter Country. 2 characters max.

8. B. SERVICE MEMBER'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY. ZIP or Postal Code. Enter first 5 digits.

8. B. SERVICE MEMBER'S PLANNED ADDRESS FOLLOWING RELEASE FROM ACTIVE DUTY. ZIP or Postal Code. Enter last 4 digits.

Page 2 27 fields

22. AUTHORIZATION FOR ALLOWANCE FOR AUTOMOBILE OR OTHER CONVEYANCE. Read information above. I CERTIFY THAT the veteran has not previously

19. PERMANENT IMPAIRMENT OF VISION. CENTRAL VISUAL ACUITY 20/200 OR LESS IN THE BETTER EYE WITH CORRECTIVE GLASSES.

SECTION 3 - CERTIFICATE OF ELIGIBILITY (To be completed by V. A.). QUALIFYING DISABILITIES (Check appropriate box(es)). 18. A. LOSS OF

18. B. LOSS OF HAND. RIGHT.

18. C. PERMANENT LOSS OF USE OF FOOT. RIGHT.

18. D. PERMANENT LOSS OF USE OF HAND. RIGHT.

20. SEVERE BURN INJURY. YES.

21. AMYOTROPHIC LATERAL SCLEROSIS (A. L S). YES.

SECTION 4 - RECEIPT FOR AUTOMOBILE OR OTHER CONVEYANCE AND ADAPTIVE EQUIPMENT (To be completed by veteran or service member). 25. MAKE AND

31. NAME OF SELLER.

32. ADDRESS OF SELLER.

27. VEHICLE IDENTIFICATION NUMBER (V I N).

23. NAME AND LOCATION OF V. A. OFFICE.

24. A. TITLE OF CERTIFYING OFFICIAL.

26. YEAR. Enter 4 digit year.

28. TOTAL PURCHASE PRICE. Enter dollar amount. First Three Digits.

28. TOTAL PURCHASE PRICE. Enter dollar amount. Middle Three Digits.

28. TOTAL PURCHASE PRICE. Enter dollar amount. Last Two Digits.

30. A. I WILL OPERATE THIS VEHICLE. YES.

30. B. I HAVE A VALID STATE DRIVER'S LICENSE OR LEARNER'S PERMIT. YES.

33. B. DATE OF RECEIPT. Enter 2 digit Day.

33. B. DATE OF RECEIPT. Enter 2 digit Month.

33. B. DATE OF RECEIPT. Enter 4 digit Year.

29. DATE OF SALE. Enter 2 digit Day.

29. DATE OF SALE. Enter 2 digit Month.

29. DATE OF SALE. Enter 4 digit Year.

24. B. DATE SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.

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Frequently asked questions

How much is the VA automobile allowance?

It is a one-time payment whose amount is set by law and adjusted periodically, so check the current figure at va.gov before you buy. Because VA pays the seller directly, get your eligibility certified before completing the purchase.

Can I get adaptive equipment more than once?

Yes. The vehicle allowance itself is one time only, but adaptive equipment can be approved more than once, for example when you replace a vehicle. Eligibility for equipment also extends to some conditions, like ankylosis of the knees or hips, that do not qualify for the allowance itself.

Does the benefit only cover cars?

No. The statute covers an automobile "or other conveyance", which VA notes can include a motorhome, commercial truck, or farm machine, as long as it provides the transportation you need.

VA Form 21-4502: Application for Automobile or Other Conveyance and Adaptive Equipment

What is VA Form 21-4502?

Who files VA Form 21-4502?

How to fill out VA Form 21-4502

Quick fill VA Form 21-4502 on this page

Frequently asked questions

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