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Get Canada Vac 918e 2012

No., PO Box, RR No.) City/Town/Village* Country* Province/Territory/State* Postal Code/ZIP* Please see reverse for additional information. Date of Service (yyyy-mm-dd) Description of Benefit(s)/Service(s) Quantity (e.g., eyeglasses, diabetic supplies, physiotherapy, etc.) Amount Claimed **Pay Provider q q q q q q ** Check box if you want Veterans Affairs Canada to pay the provider directly for the benefit(s)/service(s). The personal information provided on this form is collected under .

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