Free VA Form VA1107 - Request for Repairs, and/or Accessories - Federal

REQUEST FOR REPAIRS, AND/OR ACCESSORIES
INSTRUCTIONS WHEN REPAIRS ARE NEEDED 1. Please complete items 1 through 8 and check appropriate box in Section I - Repairs that best explains your reason for returning the device for repairs. 2. Wrap device (including transmitter, receiver, cords, tubing, etc.) in a protective foam blanket or some other protective product and place in a postal pouch with this form and mail too: Department of Veterans Affairs, Denver Distribution Center, P.O. Box 25166, Denver, CO 80225-0166. DO NOT SEND earmold, presentatin case, eyeglass fronts, etc. WHEN ACCESSORIES ARE NEEDED FOR THIS DEVICE 1. Please complete items 1 through 8 and Section II - Accessories. Indicate item(s) needed, cords, rubing, wax guards, earhooks, etc. Please indicate length when ordering cords or straight tubing. 2. Place defective items (cords or tubing if necessary) in a postal pouch along with this form and mail too: Department of Veterans Affairs, Denver Distribution Center, P.O. Box 25166, Denver, CO 80225-0166.
1. LAST NAME, FIRST NAME, MIDDLE INITIAL 2. DATE OF BIRTH (MM/DD/YYYY) 3. LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NO. 4. DATE MAILED (MM/DD/YYYY)

5. HOME MAILING ADDRESS 6. MAKE

DEVICE INFORMATION 7. MODEL

8. SERIAL NUMBER(S)

SECTION I - REPAIRS
1. DESCRIPTION OF DEFECTS (Check appropriate box(es)) DEAD NOISY 1. ITEM(S) NEEDED 2. REMARKS FADES WEAK INTERMITTENT DISTORTED MOISTURE DAMAGE EXCESSIVE BATTERY DRAIN TELE COIL DEAD/WEAK FEEDBACK

SECTION II - ACCESSORIES

VA FORM JUN 1998 (RS)

1107

(Electronic version)

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