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The VA Form 10-0103, titled "Veterans Application for Assistance in Acquiring Home Improvements and Structural Alterations," serves as a vital document for veterans or servicemembers seeking financial assistance for necessary home modifications. This form outlines a process whereby individuals can apply for benefits designed to make living spaces more accessible and conducive to their well-being, especially in cases where adjustments are needed to treat or accommodate service-connected disabilities. Applicants are required to provide detailed information about previous applications for housing benefits, personal identification, and the specific improvements or alterations they wish to undertake. Additionally, the form mandates the submission of supplementary documents, including a notarized statement from property owners for non-homeowners, itemized cost estimates, and a colored photograph of the area to be improved. It makes clear the medical and economic considerations that will be evaluated to determine eligibility, the lifetime limit on benefits, and the applicant’s responsibility for costs exceeding this limit. Notably, the VA specifies no responsibility for maintenance or liability for installed equipment. The form's completion and submission to the nearest VA Medical Center's Prosthetic and Sensory Aids Service is the first step in accessing these crucial benefits, subject to approval and compliance with the outlined requirements. This application process reflects the broader commitment to supporting veterans' health and quality of life through structural modifications to their living environments.

Preview - Va 10 0103 Form

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 Data

Fact Detail
Form Name Veterans Application for Assistance In Acquiring Home Improvements and Structural Alterations
Form Number VA 10-0103
OMB Approval Number 2900-0188
Estimated Burden Time Average 5 minutes
Eligibility Determination Based on medical and economic determinations
Cost Limitations Applies as a one lifetime benefit; cannot be exceeded for one or any accumulation of projects
Applicant Responsibility Applicants agree to pay the difference if costs exceed the allowable benefit
Governing Law Authority under Title 38, U.S.C., "Veterans Benefits"

Instructions on Utilizing Va 10 0103

Filling out the VA Form 10-0103 is a necessary step for Veterans or Servicemembers seeking assistance for home improvements and structural alterations. This process requires careful attention to detail and providing accurate information. Through this form, applicants communicate their needs for modifications or improvements to their homes, offering the Veterans Affairs (VA) the information needed to assess eligibility and potential benefits.

  1. Start by confirming whether you have previously applied for or received Home Improvements and Structural Alterations (HISA) benefits. If so, provide the date (MM/YYYY) and address of the property, along with the type of improvements, alterations, or modifications made.
  2. Indicate whether you have applied for or received other VA housing benefits by ticking the applicable box. If yes, detail the date (MM/YYYY) and address of the property where these benefits were used, along with the type of improvements, alterations, or modifications involved.
  3. Enter the Applicant's Name in the format: Last Name, First Name, Middle Initial.
  4. Fill in the Applicant's Social Security Number.
  5. Provide the Applicant's Address, including the number and street or rural route, city or P.O., state, and ZIP code.
  6. Include the Telephone Number of the applicant, making sure to add the area code.
  7. Add the E-mail Address of the applicant for additional correspondence.
  8. Describe the type of improvements, alterations, or modifications you are applying for under item 6.
  9. Under item 7, list the name of the person or company with whom you've requested the necessary labor and materials. Attach a signed copy of the estimate, which must include plans and specifications for the work to be completed by a licensed, bonded, and/or insured contractor.
  10. For non-homeowners, a notarized statement from the owner of the property authorizing the improvement or structural alteration is required. Attach this alongside a written, itemized estimate of costs for labor, materials, permits, and inspections, as well as a colored photograph of the unimproved area.
  11. Read and understand the certification section, acknowledging the conditions and limitations associated with receiving HISA benefits.
  12. If you are seeking an advance payment of HISA benefits, indicate your request by selecting Yes or No.
  13. Sign the form under item 9, providing your full name to signify your acknowledgement and acceptance of the terms stated in the form.
  14. Finally, enter the date you signed the form, using the MM/DD/YYYY format.

Upon completing the form, review all provided information for accuracy and completeness. Submit the form and any required attachments to the Prosthetic and Sensory Aids Service at the nearest VA Medical Center. After submission, your application will be assessed based on medical and economic determinations to confirm eligibility for the benefit. You will be notified about the decision and any subsequent steps you may need to take.

Obtain Answers on Va 10 0103

Frequently Asked Questions about the VA Form 10-0103

  1. What is VA Form 10-0103?
  2. VA Form 10-0103 is an application for Veterans and Servicemembers seeking assistance in acquiring Home Improvements and Structural Alterations (HISA). This benefit is aimed at helping Veterans make necessary adjustments to their homes for medical reasons related to their service.

  3. Who is eligible to apply for assistance through VA Form 10-0103?
  4. Any Veteran or Servicemember who requires home improvements or structural alterations for the effective treatment of a disability. This includes both service-connected and non-service-connected disabilities, with prioritization given based on the specific criteria set by the VA.

  5. What information is required to complete VA Form 10-0103?
  6. Applicants must provide their personal information, including their name, social security number, address, and contact details. They also need to specify the type of improvements or alterations they are seeking, provide a notarized statement if they do not own the property, and include an itemized estimate of costs, along with a colored photo of the area to be improved.

  7. Can VA Form 10-0103 be used for improvements on a property not owned by the Veteran?
  8. Yes, but a notarized statement from the property owner granting permission for the alterations is required. This ensures that the property owner is fully aware of and consents to the proposed changes.

  9. What happens after submitting VA Form 10-0103?
  10. After submission, the application will be reviewed for both medical and economic necessity. The VA will then notify the applicant about the decision. If approved, the amount of aid will be determined based on the cost of the project and the Veteran's remaining lifetime benefit limit.

  11. Is there a cost limit to the improvements and alterations covered under this form?
  12. Yes, there is a total lifetime benefit limit for each applicant, which cannot be exceeded. If the cost of a project goes beyond the remaining balance of this benefit, the Veteran agrees to cover the difference. This ensures that the benefit can serve the Veteran's needs without exceeding the program's cost limitations.

  13. What if the actual cost exceeds the estimated cost approved by the VA?
  14. If the total cost for the necessary home improvements or structural alterations ends up exceeding the VA's approved amount, the Veteran is responsible for paying the difference. The VA will not authorize benefits beyond the Veteran's total lifetime limit as established by the program.

Common mistakes

Filling out the VA Form 10-0103 can be a complex process, and mistakes can delay the approval of benefits for Home Improvements and Structural Alterations (HISA). Here are several common errors applicants should avoid:

  1. Not specifying whether they have applied for or received HISA benefits or other VA housing benefits in the past, including failure to provide dates and addresses of properties involved.
  2. Providing incomplete personal information, such as leaving out the applicant's Social Security Number or failing to provide a complete address and telephone number.
  3. Omitting the email address, which can be crucial for electronic communication and updates on the application status.
  4. Failing to clearly describe the type of improvements, alterations, or modifications being applied for, which is necessary for assessing the application.
  5. Not attaching the required documents, including a signed copy of the estimate from a licensed, bonded, and/or insured contractor, which must include plans and specifications for the work to be done.
  6. For non-homeowners, forgetting to include a notarized statement from the property owner authorizing the improvement or structural alteration.
  7. Leaving out an itemized estimate of costs for labor, materials, permits, and inspections, which is essential for determining the funding required for the project.
  8. Not providing a colored photograph of the area to be improved or altered, which helps in the assessment of the project requirements.
  9. Failure to sign and date the application, which is a mandatory step for the application to be considered valid and processed.

Applicants must ensure all sections of the form are thoroughly and accurately completed, attaching all required documents, to prevent any delays in the processing of their application for essential home improvements and structural alterations.

Documents used along the form

Completing the VA Form 10-0103 for assistance in acquiring Home Improvements and Structural Alterations is an important step for veterans or servicemembers looking to make necessary changes to their homes. To streamline the application process and ensure all necessary information is provided, there are several documents and forms that are often used in conjunction with VA Form 10-0103.

  • DD Form 214: This document serves as the certificate of release or discharge from active duty. It's crucial for verifying the veteran's service and eligibility for benefits.
  • Medical Evidence: Documentation from a healthcare provider that outlines the medical necessity for the home improvements or structural alterations. This evidence supports the application by detailing how the alterations will assist with the veteran's disability.
  • VA Form 21-4502: Application for Automobile or Other Conveyance and Adaptive Equipment. Although not directly related to home alterations, this form is frequently used by veterans applying for structural alterations to understand their full range of benefits.
  • Proof of Ownership: A deed or other documentation proving ownership of the property where the improvements will be made. For non-homeowners, a notarized statement from the property owner authorizing the work is required.
  • Estimate of Costs: An itemized estimate from a licensed contractor that includes costs for labor, materials, permits, and inspections required for the alterations. This cost breakdown is essential for determining the scope of the project and ensuring it aligns with budgetary constraints.
  • Photographs of the Unimproved Area: Color photographs that provide a visual reference of the area to be improved. These photos help in assessing the current state of the property and planning for the requested changes.

In addition to the VA Form 10-0103, these documents and forms play a critical role in the application process for home improvement and structural alteration benefits. By gathering and submitting the necessary paperwork, veterans and servicemembers can facilitate a comprehensive review of their application, ultimately aiding in the modification of their living spaces to better suit their needs.

Similar forms

The VA 10-0103 form is designed for veterans seeking assistance for home improvements and structural alterations. It shares similarities with several other documents that facilitate various types of benefits and assistance. Understanding these documents can offer a broader perspective on the support available.

  • VA Form 26-4555: Veteran's Application for Specially Adapted Housing or Special Home Adaptation Grant. Like the VA 10-0103 form, this document is used by veterans to apply for modifications to their living spaces. However, it specifically targets adaptations for disabilities incurred during service.
  • VA Form 28-1900: Disabled Veterans Application for Vocational Rehabilitation. This form serves disabled veterans seeking employment services, skills training, and educational opportunities. It is similar in its aim to provide support, though its focus is on vocational rather than housing needs.
  • VA Form 21-4502: Application for Automobile or Other Conveyance and Adaptive Equipment. This document is for veterans applying for funds to purchase a vehicle or adaptive equipment due to disabilities. It parallels the VA 10-0103 in its aim to improve quality of life through structural support.
  • VA Form 21-526EZ: Application for Disability Compensation and Related Compensation Benefits. This form is for veterans seeking compensation for disabilities. Its similarity lies in the application process for benefits based on service-related conditions.
  • HUD/VASH Application: For veterans seeking housing assistance under the HUD Veterans Affairs Supportive Housing program, this application is key. It shares the goal of the VA 10-0103 form in providing housing assistance to veterans, albeit through rental support.
  • VA Form 10-2850a: Application for Nurses and Nurse Anesthetists. Though focused on employment within VA healthcare, it's akin to the VA 10-0103 form in its part of a suite of VA services aimed at supporting veterans' personal and professional well-being.
  • SSA-16: Application for Social Security Disability Insurance (SSDI). This form is for individuals applying for disability benefits from Social Security. Like the VA 10-0103, it serves as a critical tool for individuals with disabilities seeking financial assistance, but from the Social Security Administration.
  • VA Form 22-1990: Application for VA Education Benefits. Used by veterans to apply for educational benefits under the GI Bill, it shares the purpose of providing substantial life improvements through support services, similar to what the VA 10-0103 form offers for housing.
  • Medicaid Application: For those seeking medical coverage through Medicaid, this application is vital. It's similar to the VA 10-0103 form in its goal to provide necessary medical or ancillary support, targeting a different yet overlapping population.
  • VA Form 10-10EZ: Application for Health Benefits. This form is the entry point for veterans applying for VA health benefits. It aligns with the VA 10-0103's objective of supporting veterans' health and well-being, focusing on medical rather than housing needs.

Each of these documents plays a unique role in the network of support available to veterans and other individuals. While their purposes vary, from housing adaptations and vocational rehabilitation to healthcare and education, they collectively symbolize the extensive resources aimed at improving the lives of those they serve.

Dos and Don'ts

When filling out the VA Form 10-0103 for assistance in acquiring Home Improvements and Structural Alterations, certain guidelines should be followed to ensure the application process is smooth and effective. It’s important to approach this document with attention to detail and clarity to avoid any potential delays or issues with the approval process. Below are seven do's and don'ts to consider:

  • Do ensure that all the information provided is accurate and current. Double-check details like dates, addresses, and social security numbers for any errors.
  • Do attach all the required documents, including a signed copy of the estimate, a notarized statement from the property owner (if applicable), an itemized estimate of costs, and a colored photograph of the unimproved area as specified in Section I of the form.
  • Do sign and date the application. The signature and date are crucial for validating the request. Ensure that the date format follows the mm/dd/yyyy format as indicated.
  • Do indicate whether you have applied for or received HISA benefits in the past, providing the necessary details such as date, address of property, and type of improvements or alterations made.
  • Don't leave any sections blank that are applicable to you. If a question or section does not apply, make sure to mark it as "N/A" instead of leaving it empty to indicate that you've reviewed it.
  • Don't underestimate the importance of the certification section. Review all the certifications carefully and understand the obligations, limitations, and your rights regarding the HISA benefits before signing the document.
  • Don't forget to check whether you are requesting advance payment of HISA benefits if applicable. This option should be considered carefully as it relates to the financial aspects of the home improvement or alteration project.

By adhering to these do's and don'ts, applicants can ensure that their application for the VA Form 10-0103 is completed thoroughly, accurately, and in a manner that facilitates a smoother review process. Remember, this form represents a request for significant assistance, and as such, it demands meticulous attention to detail and full compliance with the instructions provided.

Misconceptions

When it comes to understanding VA Form 10-0103, commonly known as the Veterans Application for Assistance in Acquiring Home Improvements and Structural Alterations (HISA), several misconceptions can lead to confusion and misinformation. Let’s clear up some common misunderstandings:

  • Eligibility is Only for Service-Connected Disabilities: A prevalent belief is that the HISA grant is available exclusively for veterans with disabilities that are service-connected. However, while preference may be given to those with service-connected disabilities, veterans with non-service-connected disabilities may also be eligible for HISA benefits, especially if they're rated 50% or more service-connected.

  • No Pre-approval Required: Some may think that they can commence home improvements and seek reimbursement later without prior approval. In reality, pre-approval from the VA is necessary before beginning any project. The application must be submitted and approved to ensure the modifications meet specific standards and that funding is properly allocated.

  • Benefit Limits are Flexible: Misunderstanding often surrounds the belief that the VA might exceed the stated benefit limits in certain circumstances. The limits are firm – there's a total lifetime benefit cap for HISA benefits. Once this cap is reached, no further benefits under HISA can be granted, regardless of the need or individual circumstances.

  • No Personal Contribution Required: There is a notion that veterans will not have to spend out of pocket for approved improvements. If the cost of necessary alterations exceeds the HISA grant amount, the veteran is responsible for the balance. The benefit does have a cost limit, and any expense beyond that requires personal financial responsibility.

  • All Homes Qualify: Another misconception is that HISA benefits can be applied to any property or residence. However, for renters, a notarized statement from the property owner authorizing the structural alteration is required. This underscores that not all living situations or homes may be automatically eligible for modifications under HISA without appropriate permissions and documentation.

  • Application Process is Complicated: There’s a belief that applying for HISA benefits is a lengthy and complicated process. While any application for government benefits requires attention to detail, the VA Form 10-0103 is designed to be straightforward, with an estimated burden of only 5 minutes. Correct understanding of the required documentation and prerequisites can significantly streamline the process.

Dispelling these myths ensures veterans have clear expectations and can more effectively pursue the benefits to which they are entitled, thus improving their quality of life through necessary home improvements and structural alterations.

Key takeaways

Filling out and using the VA Form 10-0103 can seem complex, but understanding its key components can simplify the process. Here are eight key takeaways to guide you through:

  • Veterans or Servicemembers must complete Section I of the application to request assistance for Home Improvements and Structural Alterations (HISA).
  • If you have previously applied for or received any HISA benefits, it's crucial to indicate the date and address of the property where improvements were made or intended.
  • Besides HISA benefits, disclosing any other VA housing benefits you've applied for or received is necessary, again providing dates and property details.
  • Applicants must attach important documents with their application, such as a notarized statement from the property owner (if not the homeowner), an itemized estimate of costs for labor and materials, and a colored photograph of the unimproved area.
  • The form requires an acknowledgment of understanding from the applicant regarding the medical and economic determinations pending for eligibility, the cost limitations as a lifetime benefit, and the applicant's responsibility for any costs exceeding the benefit limit.
  • VA Form 10-0103 emphasizes that the VA assumes no responsibility for the maintenance, repair, or replacement of the improvements, alterations, or installations. This includes no liability for damage caused by the equipment or its removal.
  • Eligibility for HISA benefits is delimited to the United States, its territories and possessions, the District of Columbia, and the Commonwealth of Puerto Rico. It's important to note that the application requires an understanding that the benefit can only be used within these areas.
  • Submitting false statements or evidence on this form can result in severe penalties, including fines or imprisonment, highlighting the importance of providing accurate and truthful information.

In summary, completing the VA Form 10-0103 requires careful attention to detail, honest disclosure of past benefits and improvements, and an understanding of the limitations and responsibilities associated with receiving HISA benefits. Proper documentation and adherence to the guidelines will ensure a smoother application process.

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