Veteran/Beneficiary Claim for Reimbursement of Travel Expenses

10-3542

NOV 2013

VA FORM

VETERAN/BENEFICIARY CLAIM FOR

REIMBURSEMENT OF TRAVEL EXPENSES

OMB Number: 2900-0798

Estimated Burden: 15 minutes

1.b Claimant's SSN

1.a Name of Person Claiming Travel Reimbursement (Last, First, Middle)

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

3.b Veteran's SSN

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

3.c Veteran'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)

Section A. Traveler's Information

Section B. Trip Information

1.a I am claiming travel reimbursement from address: (Street, City, State, Zip)

1.b Date Trip Began

(mm/dd/yyyy)

1.c Travel by:

(e.g., car, train, bus,

taxi)

2.c Travel by:

(e.g., car, train, bus,

taxi)

2.b Date Trip Ended

(mm/dd/yyyy)

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.

(If yes, itemize expenses below and provide a receipt for each expense claimed. Use reverse if additional space is required)

YES NO

4. Treating Facility Name (VA or Non-VA location)

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