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Request For Change Of Program Or Place Of Training Survivors/' And ...

OMB Approved No. 2900-0099
Respondent Burden: 20 Minutes
REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE
(Under Provisions of Chapter 35, Title 38, U.S.C.)
INTERNET VERSION AVAILABLE
You can submit this application over the Internet at the following site: www.gibill.va.gov
PART I - ALL APPLICANTS
1. NAME OF APPLICANT (First, Middle Initial, Last)
VA DATE STAMP
(For VA Use Only)
2. MAILING ADDRESS (Number and street or rural route, city or P.O., State and 9 DIGIT ZIP Code)
3A. SOCIAL SECURITY NUMBER OF APPLICANT
3B. DATE OF BIRTH OF APPLICANT
3C. VA FILE NUMBER
3D. SUFFIX LETTER
4A. SEX OF APPLICANT
4B. APPLICANT'S E-MAIL ADDRESS
MALE
FEMALE
5A. RELATIONSHIP OF APPLICANT TO VETERAN
5B. APPLICANT'S TELEPHONE NUMBER (Including Area Code)
SPOUSE
ADOPTED CHILD
DAY
EVENING
SURVIVING SPOUSE
STEPCHILD
CHILD
PART II - INFORMATION CONCERNING DISABLED OR DECEASED VETERAN OR INDIVIDUAL ON ACTIVE DUTY
6A. NAME OF VETERAN OR INDIVIDUAL ON ACTIVE DUTY ON WHOSE ACCOUNT BENEFITS ARE CLAIMED (First-Middle Initial-Last)
6B. SOCIAL SECURITY NUMBER
6C. VA FILE NUMBER (If known)
7. DATE OF BIRTH
8. BRANCH OF SERVICE
9. SERVICE NUMBER (If known)
10. DATE OF DEATH OR DATE
LISTED AS MISSING IN ACTION
OR P.O.W.
PART III - SPECIAL INFORMATION CONCERNING APPLICANT
11. IF YOU ARE THE SPOUSE OF A DISABLED VETERAN, IS DIVORCE OR ANNULMENT PENDING?
YES
NO
12A. IF YOU ARE THE SURVIVING SPOUSE OF A DECEASED VETERAN,
12B. DATE YOU REMARRIED
HAVE YOU REMARRIED SINCE HIS OR HER DEATH?
YES
NO
(If "Yes," complete Item 12B)
NOTE - COMPLETE ITEM 13 ONLY IF YOU ARE A CIVILIAN EMPLOYEE OF THE U.S. GOVERNMENT
13A. DO YOU EXPECT TO RECEIVE FUNDS FROM YOUR AGENCY OR DEPARTMENT 13B. SOURCE OF EDUCATIONAL ASSISTANCE FROM GOVERNMENT
FOR THE SAME COURSE FOR WHICH YOU EXPECT TO RECEIVE VA EDUCATIONAL EMPLOYMENT
ASSISTANCE? (If you check "Yes," show the source of these funds in Item 13B)
YES
NO
PART IV - APPLICANT'S MILITARY SERVICE
14. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES? (Including an initial period of active duty for training of 3 months or more OR subsequent
periods of active duty for training of 6 months or more) (If "No," skip this part and continue to Part V)
YES
NO
15. INFORMATION ABOUT YOUR PERIODS OF ACTIVE DUTY (Please complete Items 15A through 15D for each period of your active duty)
A. DATE ENTERED
B. DATE SEPARATED
C. BRANCH OF SERVICE OR RESERVE
D. CHARACTER OF
ACTIVE DUTY
FROM ACTIVE DUTY
OR GUARD COMPONENT
DISCHARGE
VA FORM
FEB 2007
22-5495
EXISTING STOCKS OF VA FORM 22-5495, JAN 2004,
WILL BE USED.
PART V - YOUR PROGRAM
16. HOW WILL YOU TAKE TRAINING ?
A.
SCHOOL ATTENDANCE
D.
FARM COOPERATIVE
B.
CORRESPONDENCE COURSE - Spouse or Surviving Spouse Only
E.
LICENSING OR CERTIFICATION TEST
C.
APPRENTICESHIP OR ON-THE-JOB TRAINING
F.
NATIONAL ADMISSIONS EXAMS OR NATIONAL
EXAMS FOR CREDIT
17A. WHAT EDUCATION, PROFESSIONAL OR VOCATIONAL GOAL ARE
17B. WHAT IS THE NAME OF THE PROGRAM YOU ARE REQUESTING?
YOU WORKING TOWARD?
17C. IF CHANGING SCHOOLS, GIVE NAME AND COMPLETE ADDRESS OF NEW
17D. NAME AND COMPLETE ADDRESS OF OLD OR CURRENT SCHOOL (OR
SCHOOL OR TRAINING ESTABLISHMENT YOU ARE PLANNING TO ATTEND
TRAINING ESTABLISHMENT)
(If applicable)
17E. TELL US WHEN AND WHY YOU STOPPED TRAINING AT YOUR PRIOR SCHOOL OR TRAINING ESTABLISHMENT. IF NECESSARY, CONTINUE IN ITEM 18
"REMARKS"OR ON A SEPARATE SHEET.
18. REMARKS (If more space is needed, use the reverse or attach a separate sheet of paper)
CERTIFICATION AND SIGNATURE OF APPLICANT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.
PENALTY - Willful false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the
forfeiture of these or other benefits and in criminal penalties.
19A. SIGNATURE OF APPLICANT (DO NOT PRINT)
19B. DATE SIGNED
INFORMATION AND INSTRUCTIONS
FOR COMPLETING THE REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE
This form is available on the Internet. To submit your application electronically, go to www.gibill.va.gov and click on "Education
Benefits", then on "Apply For GI Bill Benefits On Line". Follow the instructions in VONAPP (Veterans On-Line Application). To
complete a "PDF" version of this form, go to www.gibill.va.gov and click on "Education Benefits", then "Education Forms", and scroll
down to VA Form 22-5495 and click on Adobe PDF. (You must then print the completed PDF form. After completing and printing, see
HOW TO FILE YOUR CLAIM at the end of these instructions.)
Tear off these instructions from the remainder of the form. Placing these instructions next to the application form can assist you as
you complete each item.
If you submit your application electronically, VA will automatically transfer your application to the Regional Processing Office that will
handle your claim.
If you submit your application on the paper version, see HOW TO FILE YOUR CLAIM at the end of these instructions.
INSTRUCTIONS FOR SPECIFIC ITEMS
NOTE: These numbers match the Item numbers on the application.
ITEM 3A. Show your Social Security Number. (VA cannot process
ITEM 15. Benefits under this program are not payable while you
your application without this information.)
are serving on active duty in the Armed Forces.
ITEM 3C. Your VA FILE NUMBER is the number that appears on
ITEM 16. Self explanatory, except for the following items:
your VA benefit checks and all mail that we've sent you. Usually,
this VA FILE NUMBER is the veteran's Social Security Number;
Check the "Licensing or Certification Test" block if you want
however, this FILE NUMBER can be an eight digit number.
reimbursement for a licensing or certification test.
(A licensing test is a test offered by a state, local, or federal
ITEM 3D. Your SUFFIX LETTER indicates your relationship to the
agency which is required by law to practice an occupation.
veteran. The spouse or surviving spouse automatically gets the suffix
A certification test is a test designed to provide an affirmation of
of "W". Each child automatically gets a suffix with a different letter.
an individual's qualification in a specific occupation.)
(The first child that applies for VA education benefits automatically
receives the "A" suffix. The second child that applies automatically
The best way to claim this licensing or certification benefit is for
receives the"B"suffix, and so forth.)
you to send VA a copy of your test results with a note or a VA
Form 21-4138, Statement in Support of Claim, stating that you are
ITEM 6C. VA may have assigned the veteran or individual an eight-
requesting reimbursement.
digit file number. If you know this number, write it in the space
provided.
Include the following:
1.The name of the licensing or certification test you took
ITEM 11 and 12. Eligibility will terminate in the event a spouse is
2. The name and address of the organization issuing the
divorced from the veteran or in the event a surviving spouse is
license or certificate (not necessarily the organization that
remarried, unless the remarriage is both after the surviving spouse's
administered the test)
57th birthday and on or after January 1, 2004.
3.The date you took the test
4.The cost of the test
Note: A surviving spouse who terminates a remarriage may re-
5.The following signed statement: "I authorize release of
establish eligibility, but will not qualify for an extension of the ten-
my test information to VA."
year or twenty-year eligibility period.
Continuation of ITEM16.
Include the following:
Check the "National admission exams or national exams for
1.The name of the test you took.
2.The name and address of the organization offering the test.
credit" block if you want VA to reimburse you for the fee you
3.The date you took the test.
paid for taking one or more national tests.
4.The cost of taking the test.
National tests for admission to institutions of higher learning
5. The following signed statement: "I request reimbursement
include the following: the ACT, the Dental Admissions Test, the
for the cost of a national test."
Graduate Record Exam, the Graduate Management Admissions
Test, the Law School Admission Test, the Medical College
ITEM 17A. If you have decided on your educational, professional or
vocational goal, list your final objective (for example, Masters
Admissions Test, the Miller Analogies Test, the Optometry
Degree, Certified Public Accountant, Computer Technician).
Admissions Test, the Pharmacy College Admissions Test, the
Scholastic Aptitude Test, and the Test of English as a Foreign
ITEM 17C. If you have selected your new school or training
Language.
establishment, state the complete name and mailing address of this
National tests providing an opportunity for course credit at
facility.
institutions of higher learning include the following: the
ITEM 18. Use this space to provide information which does not fit
Advanced Placement exam, the College-Level Examination
elsewhere on this form or which you think will help VA process your
Program, and the DANTES Subject Standardized Tests.
claim. Refer to other item numbers on this form to help us match
your answers to the correct question. Attach additional sheets of
paper if necessary.
HOW TO FILE YOUR CLAIM
If you have already completed this application and submitted it using the Internet, do the following:
If you have selected a school or training establishment,
• Send VA your signature to finalize your Internet submission,
• Notify the veteran's certifying official at your school or training establishment that you have applied for VA education benefits, and
• Ask the veteran's certifying official to certify your school attendance.
If you have not selected a school or training establishment,
• Send VA your signature to finalize your Internet submission, and
• Wait for VA to process your application and notify you of the decision concerning your eligibility for education assistance.
If you have not already submitted this application using the Internet, do the following:
• Mail your completed application to the Regional Processing Office in the region of your home address using the chart below.
• Later, after you have selected a school or training establishment, notify the veteran's certifying official that you have applied for VA
education benefits, and
• Ask the veteran's certifying official to certify your school attendance.
MORE HELP - If you need more help completing this application or you want information about our work-study program, call VA toll-
free at 1-888-GI-BILL-1 (1-888-442-4551). If you are hearing impaired, call us toll-free at 1-800-829-4833. You can also get education
assistance after normal business hours at our education Internet site www.gibill.va.gov.
Eastern Region:
Central Region:
VA Regional Office
VA Regional Office
P. O. Box 4616
P. O. Box 66830
Buffalo, NY 14240-4616
St. Louis, MO 63166-6830
SERVES THE FOLLOWING STATES
SERVES THE FOLLOWING STATES
CT
DE
DC
ME
CO
IA
IL
IN
MD
MA
NH
NJ
KS
KY
MI
MN
NY
OH
PA
RI
MO
MT
NE
ND
VT
VA
WV
Foreign Schools
SD
TN
WI
WY
Western Region:
Southern Region:
VA Regional Office
VA Regional Office
P. O. Box 8888
P. O. Box 100022
Muskogee, OK 74402-8888
Decatur, GA 30031-7022
SERVES THE FOLLOWING STATES
SERVES THE FOLLOWING STATES
AK
AR
AZ
CA
AL
FL
GA
MS
HI
ID
LA
NM
NC
PR
SC
NV
OK
US Virgin
OR
Philippines
Islands
TX
UT
WA
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
Title 38, Code of Federal Regulations 1.526 for routine uses as identified in VA's system of records, 58VA21/22, Compensation, Pension, Education and Rehabilitation
Records - VA, and published in the Federal Register. An example of routine use allows VA to send educational forms or letters with a veteran's identifying information to
the veteran's school or training establishment to (1) assist the veteran in the completion of claims forms or (2) for VA to obtain further information as may be necessary from
the school for VA to properly process the veteran's education claim or to monitor his or her progress during training. Your obligation to respond is required to obtain or
retain education benefits. The requested information is considered relevant and necessary to determine the maximum benefits under the law. Payment of education benefits
cannot be made unless the information is furnished as required by existing law (38 U.S.C. 3513). The responses you submit are considered confidential (38 U.S.C. 5701).
Information is submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine your eligibility for education benefits (38 U.S.C. 3513). Title 38, United States Code, allows us to ask
for this information. We estimate that you will need an average of 20 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can
call 1-888-GI-BILL-1 (1-888-442-4551) to get information on where to send comments or suggestions about this information collection.