Transcription of OMB Number: 2900-0798
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Example: dental hygienist
OMB Number: 2900-0798
10-3542 NOV 2013VA FORMVETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES OMB number : 2900-0798 Estimated Burden: 15 minutes Claimant's SSN Name of Person Claiming Travel Reimbursement (Last, First, Middle) Claimant's Date of Birth (mm/dd/yyyy) Veteran's Name of Veteran (Last, First, Middle) Veteran's Date of Birth (mm/dd/yyyy) Claimant's status: (check one) Complete , , and if Caregiver, Attendant or Donor is (National Caregiver Program)Section A. Traveler's InformationSection B. Trip I am claiming travel reimbursement from address: (Street, City, State, Zip) Date Trip Began (mm/dd/yyyy) Travel by: ( , car, train, bus, taxi) Travel by: ( , car, train, bus, taxi) Date Trip Ended (mm/dd/yyyy) I am claiming return travel reimbursement to the address in aboveYESNO (if no, provide the Street, City, State, Zip below) 3.
this information if it does not display a currently valid OMB control number. This information is collected under 38 CFR 70 and is intended to fulfill the need for Veterans and beneficiaries to claim Beneficiary Travel benefits and for VA to determine the individual's eligibility for the benefit.
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