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The VA 10-0103 form serves a significant role for veterans and servicemembers seeking assistance with home improvements and structural alterations. This application is specifically designed to facilitate the process of obtaining funds for necessary modifications to better accommodate their lifestyle and medical needs. As you explore this form, you will notice that it requires vital information, such as your name, contact details, and specifics regarding previous benefits received. Applicants will be asked to indicate if they have previously applied for or received Home Improvements and Structural Alterations (HISA) benefits, in addition to other VA housing benefits. The form also necessitates an explicit description of the desired improvements or alterations, alongside the name of a contractor and a detailed estimate of costs. Further, applicants must attach several documents, including a notarized statement from the property owner for non-homeowners, a written itemized estimate, and a colored photograph of the area to be improved. Importantly, the application highlights that funding limitations apply; the VA will only cover costs up to a certain lifetime limit, which underscores the importance of detailed project planning and budget management. Acknowledging this process not only helps maintain compliance but also assists the VA in evaluating eligibility while providing essential support to those who have served. This application, thus, represents a critical step in ensuring that veterans can achieve home adaptations that enhance their quality of life.

Va 10 0103 Example

OMB Approval No. 2900-0188

Estimated Burden: Avg. 5 min.

VETERANS APPLICATION FOR ASSISTANCE

In Acquiring Home Improvements and Structural Alterations

INSTRUCTIONS: SUBMIT THIS APPLICATION TO THE PROSTHETIC AND SENSORY AIDS SERVICE TO

THE NEAREST VA MEDICAL CENTER

SECTION I - VETERAN/SERVICEMEMBER APPLICATION (To be completed by Veteran or Servicemember)

HAVE YOU APPLIED OR RECEIVED HOME IMPROVEMENTS AND STRUCTURAL ALTERATIONS (HISA) IN THE PAST?

NO

YES If "Yes" give

(1) DATE

 

(MM/YYYY) AND ADDRESS OF PROPERTY

TYPE OF IMPROVEMENTS, ALTERATIONS, MODIFICATIONS

HAVE YOU APPLIED OR RECIEVED OTHER VA HOUSING BENEFITS (I.E., SPECIALLY ADAPTED HOUSING, SPECIAL HOME ADAPTATION GRANT, OR VOCATIONAL REHABILITATION AND EMPLOYMENT'S INDEPENDENT LIVING)?

NO

YES If "Yes" give

 

 

 

 

(1) DATE

 

(MM/YYYY) AND ADDRESS OF PROPERTY

 

 

 

 

 

TYPE OF IMPROVEMENTS, ALTERATIONS, MODIFICATIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. NAME OF APPLICANT (LAST NAME, FIRST NAME, MI)

2. APPLICANT'S SOCIAL SECURITY NO.

 

 

 

 

 

 

 

 

 

3. APPLICANT'S ADDRESS

4. TELEPHONE NUMBER OF APPLICANT (Include Area Code)

 

(Number and Street or Rural Route, City or P.O., State and ZIP Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. E-MAIL ADDRESS OF APPLICANT

 

6.WHAT TYPE OF IMPROVEMENTS, ALTERATIONS, MODIFICATIONS ARE YOU APPLYING FOR:

7.NAME OF PERSON OR COMPANY WITH WHOM I SATISFACTORILY REQUEST FOR NECESSARY LABOR AND MATERIALS

(Attach a signed copy of estimate which includes plans and specification for work to be done by a licensed, bonded, and/or insured contractor).

8.IN ORDER TO COMPLETE THE HISA APPLICATION ATTACH THE FOLLOWING TO THIS APPLICATION:

FOR NON-HOME OWNERS - A NOTORIZED STATEMENT FROM THE OWNER OF THE PROPERTY AUTHORIZING THE IMPROVEMENT OR STRUCTURAL ALTERATION TO THE PROPERTY

A WRITTEN ITEMIZED ESTIMATE OF COSTS FOR LABOR, MATERIALS, PERMITS, AND INSPECTIONS FOR THE HOME IMPROVEMENT AND STRUCTURAL ALTERATION

A COLORED PHOTOGRAPH OF THE UNIMPROVED AREA

CERTIFICATION

I am applying for assistance in acquiring Home Improvements and Structural Alterations.

*I understand that there are medical and economic determinations yet to be considered before I am eligible for this benefit, and that I will soon be notified of the action taken on this application.

*I understand that cost limitations for improvements and structural alternations apply in the aggregate as a one lifetime benefit. Entitlements to this benefit terminates when the cost limit is reached. Limitations cannot be exceeded either for one project or for any accumulation of projects.

*When the anticipated total cost of a necessary or appropriate home improvements or structural alterations exceeds the remaining balance of my allowable benefit, I agree to pay the difference or the benefit will not be authorized.

*I acknowledge that the VA assumes no responsibility for maintenance, repair or replacement of requested improvements, alterations or installations; assumes no product liability for, and extends no warranties, expressed or implied, including merchantability, as to equipment or devices installed; and assumes no liability for damage caused by such equipment or devices or for their removal.

*I understand that this benefit can only be used within each of the several States, Territories, and Possessions of the United States, the District of Columbia, and the Commonwealth of Puerto Rico.

*If approved for HISA benefits, are you requesting advance payment of HISA benefits? (VA may make an advance payment to the beneficiary

equal to 50 percent of the total benefit authorized for the improvement of structural alteration). YES NO

9. SIGNATURE OF APPLICANT (Sign Full Name)

10. DATE SIGNED (mm/dd/yyyy)

The law provides severe penalties including fine or imprisonment , or both, for willful submission

of any false statement or evidence of material fact.

JUN 2015

10-0103

Page 1 of 2

VA FORM

 

 

VETERANS APPLICATION FOR ASSISTANCE IN ACQUIRING HOME IMPROVEMENTS AND STRUCTURAL ALTERATIONS, CONTINUED

SECTION II - (FOR VA USE ONLY) HISA COMMITTEE ACTION

HOME IMPROVEMENTS AND STRUCTURAL ALTERATIONS IS NECESSARY:

TO ASSURE THE CONTINUATION OF TREATMENT OF APPLICANT'S DISABILITY (Specify the disability for which the home improvement or structural alteration is necessary or appropriate)

TO PROVIDE ACCESS TO THE HOME OR TO ESSENTIAL LAVATORY AND SANITARY FACILITIES FOR TREATMENT OF: A SERVICE-CONNECTED DISABILITY

A NONSERVICE-CONNECTED DISABILITY OF A VETERAN WITH SERVICE CONNECTED DISABILITIES RATED 50%OR MORE

COST LIMITATION

TOTAL LIFETIME BENEFIT: $

AMOUNT APPROVED $

TOTAL PAID TO DATE $

TOTAL REMAINING $

ASSISTANCE IN THE AMOUNT OF $

 

 

APPROVED. (Letter of approval will state this amount, subject to

amendment for inclusion of acceptable costs omitted in this application or found to be unnecessary.)

 

ADVANCE PAYMENT IN THE AMOUNT OF $

 

 

PAID ON

(MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FINAL PAYMENT IN THE AMOUNT OF $

 

PAID ON

(MM/DD/YYYY)

 

 

 

 

 

 

 

APPLICATION DISAPPROVED

 

 

 

 

 

REMARKS:

SIGNATURE OF APPROVING OFFICIAL (HISA COMMITTEE CHAIRMAN, PROSTHETIC REPRESENTATIVE, CHIEF of PROSTHETICS)

DATE (mm/dd/yyyy)

PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C., "Veterans Benefits, and will be used to determine your eligibility/entitlement and reimbursement of individual claims for home improvement and structural alterations, and identify your medical records. Additional information may be solicited during the course of processing your application. The information you supply may also be disclosed outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records' 24VA136, published in the Federal Register. Disclosure is voluntary, however, failure to furnish the information will result in our inability to process your request promptly and serve your medical needs. Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

JUN 2015

10-0103

Page 2 of 2

VA FORM

 

 

Form Characteristics

Fact Name Detail
Form Purpose The VA Form 10-0103 is used by veterans to apply for assistance with home improvements and structural alterations.
OMB Approval Number The form has the OMB Approval No. 2900-0188.
Estimated Completion Time The estimated burden for completing the form is about 5 minutes on average.
Submission Instructions This application should be submitted to the Prosthetic and Sensory Aids Service at the nearest VA Medical Center.
Eligibility Requirements Applicants must provide information about prior home improvement benefits received and details about the current request.
Supporting Documents Non-homeowners must attach a notarized statement from the property owner that authorizes the improvements.
Legal Compliance Submission of false information can result in severe penalties, including fines or imprisonment.
Benefit Territory The benefits from this application can be used only within the United States, its territories, and possessions.

Guidelines on Utilizing Va 10 0103

After completing the VA Form 10-0103, the next step is to submit the application to the Prosthetic and Sensory Aids Service at the nearest VA medical center. Ensure that all required documentation is included to avoid delays in processing.

  1. Begin with Section I, answering whether you have applied for or received Home Improvements and Structural Alterations (HISA) in the past. Mark "Yes" or "No."
  2. If "Yes," provide the date (MM/YYYY), the property address, and the type of improvements, alterations, or modifications made.
  3. Answer whether you have applied or received other VA housing benefits. Again, choose "Yes" or "No."
  4. If "Yes," fill in the date (MM/YYYY), the property address, and the type of benefits received.
  5. In section 1, list your name (last name, first name, MI).
  6. Enter your social security number.
  7. Provide your address (number and street or rural route, city or P.O., state, and ZIP code).
  8. Include your telephone number with area code.
  9. List your email address.
  10. Specify the type of improvements, alterations, or modifications you are applying for.
  11. Provide the name of the person or company from whom you are requesting the necessary labor and materials. Attach a signed copy of the estimate that includes plans and specifications.
  12. If you are a non-homeowner, attach a notarized statement from the property owner authorizing the improvements or structural alterations.
  13. Attach a written itemized estimate of costs for labor, materials, permits, and inspections.
  14. Include a colored photograph of the unimproved area.
  15. Read the certification statements. Confirm your understanding of the terms, and sign your full name.
  16. Enter the date you are signing the application (MM/DD/YYYY).

Ensure all information is accurate before submitting the form. Double-check for any required attachments to facilitate a smooth review process.

What You Should Know About This Form

What is the VA 10-0103 form used for?

The VA 10-0103 form, also known as the Veterans Application for Assistance in Acquiring Home Improvements and Structural Alterations, is designed for veterans and servicemembers seeking financial assistance for necessary home modifications. These improvements can help accommodate disabilities, enhance accessibility, or support ongoing treatment of service-related conditions. By completing this form, applicants can initiate the process to receive funding for modifications that will improve their living situation.

Who is eligible to apply for benefits using this form?

Eligibility for benefits via the VA 10-0103 form generally includes veterans who have service-connected disabilities. The modifications requested must be necessary to accommodate the veteran's disability, provide access to essential facilities, or ensure ongoing treatment for the disability. In some cases, family members of veterans may also qualify. It's important to ensure that any previous applications for similar benefits are disclosed when applying.

What information is required to complete the form?

To fill out the VA 10-0103 form, applicants will need to provide personal information, including their name, Social Security number, address, contact information, and email address. Additionally, information about past applications for home improvements or other VA housing benefits must be disclosed. Details concerning the specific type of improvements requested, along with estimates for labor and materials, must also be included. Don’t forget to attach a notarized statement if you are not the property owner.

What documents must accompany the VA 10-0103 form?

When submitting the VA 10-0103 form, applicants need to provide several key documents. These include a notarized statement from the property owner (if the applicant is not the owner), a written itemized estimate of costs associated with the desired improvements, and a colored photograph of the area needing modification. These documents help substantiate the application and give the VA a complete understanding of the requested changes.

How long does it take to process the application?

The processing of the VA 10-0103 application can vary based on individual circumstances and the volume of applications being processed at any given time. While the form itself may take about 5 minutes to complete, applicants should be prepared for additional time needed for the VA to review their case, which could range from weeks to months. Applicants will be notified of the decision regarding their application once it has been processed, so staying patient during this time is crucial.

What should I do if my application is denied?

If your application for HISA benefits using the VA 10-0103 form is denied, you have the right to appeal the decision. It's important to carefully review the reasons for denial outlined in the notification you receive. Gathering additional supporting documentation and addressing the concerns raised may help strengthen your case. Consider reaching out to a veterans service organization for assistance on how to navigate the appeal process effectively and increase your chances of obtaining the requested benefits.

Common mistakes

Completing the VA Form 10-0103 can be a crucial step for veterans seeking assistance in making home improvements. However, many applicants make common mistakes that can lead to delays or denials. Understanding these pitfalls can help ensure a smoother application process.

One significant mistake is failing to provide accurate and complete information. A common oversight involves not including the applicant's social security number or making typographical errors in the name or address. Such inaccuracies can hinder the processing of the application, as the VA may require additional time to verify the correct details. It is essential to double-check all entries for clarity and accuracy before submission.

Another frequent error arises from incomplete responses to the questions posed in the form. For instance, questions regarding previous applications for home improvements or other VA housing benefits need to be fully addressed. If a veteran has received assistance before, they must provide the exact dates and details of prior benefits. Omitting this information can be seen as a lack of transparency, potentially leading to an application being rejected.

The documents attached to the application often fall short of requirements. Applicants sometimes fail to include a signed estimate from a licensed contractor or neglect to attach a notarized statement if they are not homeowners. Without these essential documents, the application will not meet the necessary criteria for review. Careful attention to the required attachments is crucial for a successful submission.

Finally, many applicants overlook the certification and acknowledgment sections of the form. It is important that veterans fully understand the stipulations related to cost limitations and liability issues. By not reading these sections carefully, an applicant might inadvertently misstate their understanding or agreement with the terms. This can result in complications later in the application process.

In summary, by taking the time to review the form carefully, providing accurate and complete information, ensuring that all required documents are attached, and understanding the terms presented, applicants can greatly improve their chances of receiving the assistance they seek.

Documents used along the form

The VA 10-0103 form is an essential document for veterans applying for assistance in acquiring home improvements and structural alterations. However, this form often goes hand-in-hand with other important documents that help streamline the process and substantiate the application. Familiarizing yourself with these additional forms can enhance the chances of a successful application and ensure all necessary information is provided. Below is a list of up to ten commonly used forms and documents associated with the VA 10-0103.

  • VA Form 26-4555: This is the application for a Specially Adapted Housing Grant. Veterans who require modifications to make their homes more accessible often submit this form to apply for funding.
  • VA Form 21-2680: Known as the Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, this document assesses a veteran's need for assistance in daily living activities, which may affect housing improvements.
  • VA Form 21-534EZ: This form serves as an application for Dependency and Indemnity Compensation (DIC) and/or Death Pension, which can be relevant for veterans' families involved in home acquisitions or alterations.
  • VA Form 55214: This document allows veterans to request an increase in their home loan guaranty. An increase can help cover the costs associated with home improvements.
  • VA Form 10-10172: The Veterans Health Administration (VHA) Authorization Form allows healthcare providers to authorize certain services, which can include recommendations for home modifications to improve health outcomes for veterans.
  • VA Form 10-0143: This is the application for Home Improvements and Structural Alterations (HISA) benefits. If applying for a non-standard benefit or enhancement of an existing application, this form might be necessary.
  • Estimate and Invoice Documents: These documents outline the projected and actual costs of the proposed home improvements. They're crucial as they provide transparency and justification for funding requests.
  • Notarized Owner Authorization: For those who do not own their homes, a notarized statement from the property owner is necessary to authorize improvements, which is a stipulation in the application process.
  • Colored Photographs: A set of colored photographs showcasing the areas in need of improvement or modification can be crucial in visually supporting the application.
  • Home Assessment Report: Conducted by a qualified inspector, this report assesses the home to identify necessary changes. It can verify the need for alterations requested on the VA 10-0103 form.

Each of these documents plays a unique role in supporting an application for home improvements and structural alterations for veterans. Understanding their purpose and ensuring proper submission can streamline the process and potentially result in a successful outcome. When seeking assistance, it is always beneficial to gather all relevant documents beforehand to avoid delays and ensure a comprehensive application.

Similar forms

  • VA Form 10-0104: This form is similar as it is also a request for home improvement assistance. Both forms require information about the applicant, type of improvements needed, and previous benefits received.
  • VA Form 26-4555: This application is for veterans seeking a Specially Adapted Housing grant. Like the 10-0103, it collects details on disabilities and the specific accommodations required for living spaces.
  • VA Form 21-2680: This document is used for determining the need for aid and attendance benefits. It captures similar information regarding the applicant's medical condition and the requirements for safe living environments.
  • VA Form 10-0139: This form pertains to requests for long-term care. Both documents consider the health and well-being of veterans while assisting with their housing needs.
  • VA Form 26-1817: This is used for veterans applying for a VA loan. It shares elements related to financial assistance and home modifications, focusing on different aspects of home accessibility.
  • VA Form 21-4502: This form is aimed at veterans seeking benefits for vocational rehabilitation and employment. It parallels the 10-0103 in its emphasis on how housing modifications can play a role in supporting an independent lifestyle.

Dos and Don'ts

When filling out the VA 10-0103 form, following the right steps is critical to ensure your application is processed smoothly. Here is a list of dos and don'ts that can help you navigate this process effectively.

  • DO read all the instructions carefully before starting to fill out the form.
  • DO provide accurate and complete information in each section, especially in the applicant's name and address.
  • DO attach all required documentation, such as estimates from licensed contractors, if applicable.
  • DO ensure that any estimates included specify the labor and materials required for the improvement.
  • DON'T leave any important fields blank; missing information could delay processing.
  • DON'T submit the application without reviewing it for any spelling or factual errors.
  • DON'T assume the VA has your previous application information; always provide all necessary details again.
  • DON'T forget to sign and date the application before submitting it.

By adhering to this list, you can minimize errors and expedite your request for home improvements or structural alterations. It is important to act promptly to enhance your living conditions while ensuring compliance with the application requirements.

Misconceptions

Misconceptions surrounding the VA Form 10-0103 can lead to confusion for veterans seeking assistance with home improvements and structural alterations. The following list identifies six common misconceptions and provides clarifications for each.

  • Misconception 1: The VA provides unlimited funding for home improvements.
  • This is incorrect. The VA limits the benefits for home improvements to a total lifetime amount. Once this limit is reached, veterans cannot receive further assistance for additional projects.

  • Misconception 2: Only homeowners can apply for assistance.
  • This is not necessarily true. Non-homeowners can apply as well, but they must provide a notarized statement from the property owner authorizing the proposed changes.

  • Misconception 3: The process is quick and applications are always approved.
  • The reality is that the application process takes time, and not all requests are granted. Eligibility and medical assessments determine the approval status. Each application will be evaluated based on individual circumstances.

  • Misconception 4: VA assumes responsibility for maintenance of improvements made.
  • This is false. The VA explicitly states it holds no responsibility for maintenance, repair, or replacement of any improvements funded through the program.

  • Misconception 5: The application can be submitted at any time without specific preparation.
  • This misconception overlooks the requirement to attach supporting documents, such as cost estimates and photographs of the area in need of improvement. Proper preparation is essential before submitting the application.

  • Misconception 6: Advances on HISA benefits are guaranteed.
  • While veterans can request advance payments, these are not guaranteed. The VA assesses requests individually based on the total approved benefit and the project costs.

Understanding these misconceptions can better inform veterans applying for home improvements and help streamline the process of obtaining assistance.

Key takeaways

Here are key points to consider when filling out and using the VA Form 10-0103.

  • The form is officially known as the Veterans Application for Assistance in Acquiring Home Improvements and Structural Alterations.
  • It must be submitted to the Prosthetic and Sensory Aids Service at the nearest VA medical center.
  • Applicants should be prepared to indicate if they have previously applied for Home Improvements and Structural Alterations (HISA).
  • Providing accurate personal information, including the name, address, and Social Security number, is essential.
  • If applicable, include details about other VA housing benefits received.
  • Attach supporting documents, such as a notarized statement from the property owner when the applicant is not a homeowner.
  • Include an itemized estimate of costs associated with the proposed improvements.
  • A colored photograph of the area requiring improvement must also be submitted.
  • Note that there are cost limitations on approved projects; this benefit is limited to a one-time lifetime entitlement.
  • Understand that VA does not assume responsibility for the maintenance or replacement of any improvement made.