Fillable APPLICATION FOR REIMBURSEMENT OF LICENSING OR CERTIFICATION TEST (Lorain County Community College)

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APPLICATION FOR REIMBURSEMENT OF LICENSING OR CERTIFICATION TEST (Lorain County Community College)

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VA FORM
DEC 2016
22-0803
1. NAME OF APPLICANT (First, Middle Initial, Last Name)
3. VA FILE NUMBER (For chapter 35, enter the veteran's file number. Be
sure to include the suffix indicator. For dependent transfer cases, enter
the file number of the person who transferred entitlement to you.)
B. WHAT EDUCATION BENEFIT HAVE YOU APPLIED FOR PREVIOUSLY?
4. SOCIAL SECURITY NUMBER (If not shown in Item 3.)
PART I - IDENTIFICATION INFORMATION
I hereby authorize the release of my test information to the Department of Veterans Affairs (VA).
IMPORTANT: To apply for reimbursement of a licensing or certification test fee, please return this form to the VA office which handles your area.
See the addresses on page 2 of this form. Include a copy of your test results.
9. DATE TEST TAKEN AND TEST RESULTS (See the Instructions for this
item for information and evidence you must specify or attach to this
application.) (If more space is needed, use Item 11 Remarks.)
10. COST OF TEST INCLUDING MANDATORY FEES (Specify for
each test) (If more space is needed use Item 11 Remarks)
11. REMARKS
APPLICATION FOR REIMBURSEMENT OF LICENSING OR
CERTIFICATION TEST FEES
OMB Approved No. 2900-0695
Respondent Burden: 15 Minutes
Expiration Date: 3/31/2018
12. SIGNATURE OF APPLICANT 13. DATE SIGNED
IMPORTANT: Complete this application to apply for reimbursement of licensing or certification test fees. You must apply separately for VA
education benefits if you have not already done so. You can receive reimbursement of a licensing or certification test fee if you qualify for VA
benefits under one of the following programs:
(See the reverse for Information and Instructions for completing this form.)
5. TELEPHONE NUMBER AND HOURS VA CAN REACH YOU
(Include Area Code)
2. MAILING ADDRESS OF APPLICANT (Number and street or rural route, city or P. O., State and ZIP Code)
C. WHAT EDUCATION BENEFIT ARE YOU APPLYING FOR NOW?
6. VA EDUCATION INFORMATION
A. HAVE YOU PREVIOUSLY APPLIED FOR VA EDUCATION BENEFITS?
(If "No," you should complete an application for education benefits.)
7. NAME OF TEST (Specify for each test) (If more space is needed use Item
11 Remarks.)
8. COMPLETE NAME AND MAILING ADDRESS OF ORGANIZATION
ISSUING LICENSE OR CERTIFICATION (Specify for each test.)
PART II - TEST INFORMATION
(If "Yes," show the specific benefit you previously applied for in Item 6B.)
SUPERSEDES VA FORM 22-0803, MAR 2015,
WHICH WILL NOT BE USED.
Montgomery GI Bill - Active Duty Educational Assistance Program (MGIB) (Chapter 30)
Reserve Educational Assistance Program (REAP) (Chapter 1607)
Montgomery GI Bill - Selected Reserve Program (MGIB-SR) (Chapter 1606)
Survivors' and Dependents' Educational Assistance Program (DEA) (Chapter 35)
Post-9/11 GI Bill (Chapter 33)
Post-Vietnam Era Veterans Educational Assistance Program (VEAP) (Chapter 32)
YES
CHAPTER 30
NO
CHAPTER 32 CHAPTER 1607 CHAPTER 1606 CHAPTER 35CHAPTER 33
Page 1
INFORMATION
(The items that are considered self-explanatory are not included in these instructions.)
ITEM 3. If you (or the veteran or serviceperson) were previously assigned an 8-digit file number, enter this number.
ITEM 6. If you have not previously applied for VA education benefits, go to www.benefits.va.gov/gibill/
, and click on "Apply for
Benefits". See the top of this form for the education benefits that permit reimbursement of Licensing or Certification tests.
ITEM 7. Write the complete name of the test.
ITEM 8. Write the complete name and complete mailing address (including ZIP Code) of the organization issuing the license or
certificate (not necessarily the organization that administered the test).
ITEM 9. Show the date you took the test and attach a copy of your test results. (If you do not have any test results but have a copy of
your license or certification and a payment receipt for your test, attach these documents.) Reimbursement of the test fee can't be paid
until this information is received. Provide this information for each test you want to receive reimbursement.
ITEM 10. Enter the cost of the test you took, including any required fees. (We can only reimburse you for required test fees.) We
have no authority to reimburse you for any optional costs related to the test process. Test fees that VA will reimburse include
"registration fees," fees for specialized tests, and administrative fees such as a proctoring fee. Fees that VA has no authority to
reimburse include fees to take pre-testes (such as Kaplan exams), fees to receive scores quickly, or other costs or fees for optional
items that are not required to take an approved test.
ITEMS 12 and 13. Sign and date the form.
Additional Information: You may provide additional information that you think will help VA process your claim. Attach additional
sheets of paper to this application if necessary. Additional information should be properly labeled (such as: Item 1, if the additional
information supports Item 1 on the form).
MORE HELP: If you need help in completing this application, call VA TOLL-FREE at 1-888-GI-BILL-1 (1-888-442-4551). If
you use the Telecommunications Device for the Deaf (TDD), the Federal Relay number is 711. You can also get education assistance
after normal business hours at our education Internet site: www.benefits.va.gov/gibill/.
HOW TO FILE YOUR CLAIM. Send the completed application to the Regional Processing Office in the region of your home
address. Use the addresses below.
EASTERN REGION
VA Regional Office
PO Box 4616
Buffalo, NY 14240-4616
CT
DE
DC
MA
MD
ME
VA
VT
US Virgin Islands
Foreign Schools
APO/FPO AA
OH
SD
TN
WI
WV
WY
CENTRAL REGION
VA Regional Office
PO Box 32432
St. Louis, MO 63132-0832
CO
IL
IN
IA
KS
KY
MI
MN
MO
MT
NE
ND
WESTERN REGION
VA Regional Office
PO Box 8888
Muskogee, OK 74402-8888
NC
NH
NJ
NY
PA
RI
SC
TX
UT
WA
Guam
Philippines
APO/FPO AP
RESPONDENT BURDEN: We need this information to determine your eligibility for reimbursement of licensing and certification test fees. We cannot pay you any
education benefits for this reimbursement until we receive this information (38 U.S.C. 5101). We estimate that you will need an average of 15 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
http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-888-GI-BILL-1 (1-800-442-4551) to get information on where to send comments or suggestions
about this form. If you are hearing impaired, call 1-888-829-4833.
PRIVACY ACT INFORMATION: 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 1.576 for routine uses (i.e., VA sends 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) VA obtains 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) as identified in the VA system of records, 58VA21/22/28,
Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is
required to obtain or retain benefits (licensing and certification test reimbursement). While you do not have to respond, VA cannot reimburse you any licensing and
certification test fees until we receive this information (38 U.S.C. 3452(b) and 3501(a)). Your responses are confidential (38 U.S.C. 5701). Information submitted is
subject to verification through computer matching programs with other agencies.
AK
AL
AR
AZ
CA
FL
GA
HI
ID
LA
MS
NM
NV
OK
OR
PR
VA FORM 22-0803, DEC 2016
Page 2
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APPLICATION FOR REIMBURSEMENT OF LICENSING OR CERTIFICATION TEST (Lorain County Community College)

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Completed 3 October 2020

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