Fillable APPLICATION FOR VA EDUCATION BENEFITS (VA FORM 22-1990) (Community College of Allegheny County)

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APPLICATION FOR VA EDUCATION BENEFITS (VA FORM 22-1990) (Community College of Allegheny County)

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INFORMATION AND INSTRUCTIONS
FOR COMPLETING THE APPLICATION FOR VA EDUCATION BENEFITS
APPLICATION FOR VA EDUCATION BENEFITS
(VA FORM 22-1990)
22-1990
SUPERSEDES VA FORM 22-1990, DEC 2008,
WHICH WILL NOT BE USED.
VA FORM
MAY 2009
Do not use this form to apply for Vocational Rehabilitation and Employment benefits (chapter 31 of title 38, U.S. Code), Dependents
Educational Assistance benefits (chapter 35 of title 38, U.S. Code), Transfer of Entitlement, or National Call to Service (section 510 of title
10, U.S. Code). These benefits require different application forms that can be completed on-line and printed at www.va.gov/vaforms or
can be obtained from the nearest VA regional office. They may also be available where you received this application.
INTERNET VERSION AVAILABLE - You may complete and submit this application on-line at www.gibill.va.gov. Click "Apply
On Line" and select the "Education" option.
VA VOCATIONAL AND EDUCATIONAL COUNSELING HELP AVAILABLE - If you need help planning your individual
educational and career goals, VA offers a wide range of counseling services to help you make these decisions. Services include educational
and vocational guidance and such testing as necessary for you to develop a greater understanding of your skills, talents, and interests. For
further information on VA counseling, call VA toll-free at 1-888-GI-BILL-1 (1-888-442-4551) or TDD at (800) 829-4833.
NOTE: The numbers on the instructions match the item numbers on the application. Items not mentioned are self-explanatory.
Part II
(This section provides an overview of the general eligibility requirements for various education programs. Additional requirements not listed
on this form may be necessary.)
ITEM 9A. You may be eligible for benefits under the Post-9/11 GI Bill, also referred to as chapter 33, if you served at least 90 aggregate
days on active duty (excluding entry level and skill training) after September 10, 2001. You may also qualify if you were discharged due to
a service-connected disability after serving at least 30 continuous days on active duty after September 10, 2001.
ITEM 9B. You may be eligible for the Montgomery GI Bill, also referred to as MGIB or chapter 30, if you served on active duty and meet
certain conditions. NOTE: You do not have to be on active duty to apply for benefits under this program. You must meet any one of the
following conditions (there are additional requirements):
You first entered service on or after July 1, 1985, and you didn't decline this benefit at your initial entry into service
OR
You entered service (or agreed to delayed entry) before January 1, 1977, and you have educational assistance entitlement remaining under
the Vietnam Era GI Bill (also known as "chapter 34")
OR
You were voluntarily separated under the Voluntary Separation Incentive (VSI) or Special Separation Benefit (SSB) programs and had
your military pay reduced by $1,200
OR
You were involuntarily separated from active duty after February 2, 1991,
OR
You were on active duty and a participant in the Post-Vietnam Era Veterans' Educational Assistance Program (VEAP) program on or before
October 9, 1996, or you first entered the National Guard under title 32, U.S. Code, between July 1, 1985, and November 28, 1989, you
elected chapter 30 benefits between October 9, 1996, and October 8, 1997, and you paid $1,200
OR
You were on active duty and eligible for VEAP benefits on October 9, 1996, you elected chapter 30 benefits between November 1, 2000,
and October 31, 2001, and you paid $2,700.
ITEM 9C. You may be eligible for the Montgomery GI Bill - Selected Reserve Educational Assistance Program, also known as MGIB-SR
or chapter 1606, if you are a member of the Selected Reserve and meet certain requirements, including a 6-year commitment. (The
Departments of Defense and Homeland Security determine eligibility for this program.)
To expedite processing, attach a copy of your DD 2384, Selected Reserve Educational Assistance Program (GI BILL) Notice of Basic
Eligibility. This form is also called a "NOBE." Your reserve unit should have issued this notice to you when you became eligible for the
Montgomery GI Bill - Selected Reserve Educational Assistance Program. If you are unable to locate your copy, request a duplicate from
your reserve unit.
Use this form to apply for educational assistance under the following benefit programs:
Post- 9/11 GI Bill chapter 33 of title 38, U.S. Code
Montgomery GI Bill (MGIB) chapter 30 of title 38, U.S.Code
Montgomery GI Bill - Selected Reserve (MGIB-SR) chapter 1606 of title 10, U.S. Code
Reserve Educational Assistance Program (REAP) chapter 1607 of title 10, U.S. Code
Post-Vietnam Era Veterans' Educational Assistance Program (VEAP) chapter 32
of title 38, U.S. Code, or section 901 or section 903 of Public Law 96-342
ITEM 9D. You may be eligible for benefits under the Reserve Educational Assistance Program (REAP), also known as chapter 1607, if
you are a member of the Ready Reserve and were called or ordered to active service to support a contingency operation for at least 90
consecutive days on or after September 11, 2001. (The Department of Defense and Homeland Security determine eligibility for this
program.)
Attach a copy of any notice of eligibility to this program that you have received from your service component. Also, attach a copy of your
orders showing you were called up to active service. If you do not have a copy of your orders, request a duplicate from your unit.
ITEM 9E. You may be eligible for benefits under the Post-Vietnam Era Veterans' Educational Assistance Program (VEAP), also known
as Chapter 32, if your service began on or after January 1, 1977, and before July 1, 1985, and you contributed to a VEAP account.
You may be eligible for benefits under the Post-Vietnam Era Non-Contributory Veterans' Educational Assistance Program, also known as
"Non-Contributory VEAP" or Section 903", if your service began on or after November 30, 1980, and before October 1, 1981, and your
branch of service paid contributions into your VEAP account.
ITEM 9F. If you are eligible for MGIB, MGIB-SR, OR REAP, you must elect to give up eligibility under the program for which you are
eligible in order to receive benefits under the Post-9/11 GI Bill (chapter 33). If you are eligible for more than one of the programs listed
(MGIB, MGIB-SR, and REAP), you are only required to give up one of the programs for which you are eligible in order to receive
benefits under the Post-9/11 GI Bill. You may not receive more than a total of 48 months of benefits under two or more programs. If you
elect chapter 33 in lieu of chapter 30, your months of entitlement under chapter 33 will be limited to the number of months of entitlement
remaining under chapter 30 on the effective date of your election. However, if you completely exhaust your entitlement under chapter 30
before the effective date of your chapter 33 election, you may receive up to 12 additional months of benefits under chapter 33. If you wish
to elect to receive benefits under the Post-9/11 GI Bill, check the box next to the program (only check one box) you are giving up.
NOTE: An election to give up benefits under an existing program and receive benefits under the Post-9/11 GI Bill is IRREVOCABLE.
You should carefully consider your decision before completing this section. If you need more information to make a choice, you should
visit our website at www.gibill.va.gov or call our toll-free customer service number at 1-888-GIBILL-1 (1-888-442-4551).
PART III
ITEM 10A. Self explanatory, except for the following items:
"Vocational Flight Training." You must already have a private pilot's license. If you are taking an Airline Transport Pilot course, you
must have a valid first-class medical certificate on the date that you enter training. For all other flight courses, you must have a valid
second-class medical certificate on the date that you enter training.
"National Test Reimbursement." You can be reimbursed for the cost of approved tests for admission to, or credit at, institutions of higher
learning.
"Licensing or Certification Test Reimbursement." A licensing test is a test offered by a state, local, or federal agency that is required by
law to practice an occupation. A certification test is a test designed to provide affirmation of an individual's qualifications in a specific
occupation. Examples include EMT, CPA, MCSE, CCNP, etc.
"Tuition Assistance Top-Up" This benefit is payable only under MGIB and the Post-9/11 GI Bill programs. You can receive benefits to
pay you for the difference between what the military pays with Tuition Assistance (TA) and the total costs of these courses.
PART VIII
QUESTIONS ARE ONLY FOR APPLICANTS WHOSE SERVICE BEGAN BEFORE JANUARY 1, 1977, (or delayed entry before January
2, 1978). If you are currently married or if you have children under age 18 (under age 23 if in school), you should complete and return
VA Form 21-686c. If your children are in school, you should also complete and return VA Form 21-674 for each child. If your parent(s)
are dependent on you for financial support, you should complete and return VA Form 21-509. These forms may require additional
documentation. VA cannot pay any additional benefits for dependents without properly completed forms and documentation. You can
find VA forms 21-686c, 21-674, and 21-509 on-line at www.va.gov/vaforms.
ADDITIONAL HELP
If you need more help in completing this application, 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.
HOW TO FILE YOUR CLAIM
Be sure to do the following:
(A) If you have selected a school or training establishment:
Step 1: Mail the completed application to the VA Regional Processing Office for the region of that school's physical address. See next
page for the addresses of these VA Regional Processing Offices.
Step 2: Tell the veterans certifying official at your school or training establishment that you have applied for VA education benefits. Ask
him or her to send your enrollment information using VA Form 22-1999, Enrollment Certification, or its electronic version.
Step 3: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.
(B) If you haven't selected a school or training establishment:
Step 1: Mail the completed application to the VA Regional Processing Office for the region of your home address. See next page for the
addresses of these VA Regional Processing Offices.
Step 2: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.
Eastern Region:
VA Regional Office
P.O. Box 4616
Buffalo, NY 14240-4616
Serves the following states:
IN
MN
ND
WY
CA
NM
PHILIPPINES
GUAM
Central Region:
VA Regional Office
P.O. Box 66830
St. Louis, MO 63166-6830
Western Region:
VA Regional Office
P.O. Box 8888
Muskogee, OK 74402-8888
Southern Region:
VA Regional Office
P.O. Box 100022
Decatur, GA 30031-7022
CO
KS
MO
SD
Serves the following states:
IA
KY
MT
TN
Privacy Act Notice: The 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, section 1.576 for routine uses (e.g., 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) for the VA to obtain further information as may
be necessary from the school for the 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, and published in the
Federal Register. Your obligation to respond is required to obtain or retain education benefits. Giving us your SSN account information is voluntary. Refusal to
provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the
disclosure of the SSN is required by a Federal Statute of law enacted before January 1, 1975, and still in effect. The requested information is considered relevant
and necessary to determine the maximum benefits under the law. While you do not have to respond, VA cannot process your claim for education assistance
unless the information is furnished as required by existing law (38 U.S.C. 3471). The responses you submit are considered confidential (38 U.S.C. 5701). Any
information provided by applicants, recipients, and others may be subject to verification through computer matching programs with other agencies.
MS
US Virgin Islands
Respondent Burden: We need this information to determine your eligibility for education benefits (38 U.S.C. 3471). Title 38, United States Code, allows us to
ask for this information. 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 (Office of Management and Budget) 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 1-800-827-1000 to get information on where to send comments or
suggestions about this form.
IL
MI
NE
WI
CT
MD
NY
VT
DE
MA
OH
VA
ME
NJ
RI
Foreign Schools
DC
NH
PA
WV
Serves the following states:
AR
ID
OK
UT
AZ
LA
OR
WA
Serves the following states:
AK
HI
NV
TX
AL
NC
FL
PR
GA
SC
APO/FPO AA
APO/FPO AP
VA FORM 22-1990, MAY 2009
22-1990
APPLICATION FOR VA EDUCATION BENEFITS
(See attached Information and Instructions)
PART II - EDUCATION BENEFIT BEING APPLIED FOR See instructions for benefit eligibility criteria
INTERNET VERSION AVAILABLE - You may complete and send your application over the Internet at: www.gibill.va.gov
SUPERSEDES VA FORM 22-1990, DEC 2008,
WHICH WILL NOT BE USED.
VA FORM
MAY 2009
PAGE 1 OF 4
1. SOCIAL SECURITY NUMBER OF APPLICANT
MALE
OMB Control No. 2900-0154
Respondent Burden: 15 minutes
FEMALE
4. NAME (First, Middle Initial, Last)
Account Number
Savings
VA DATE STAMP
(Do Not Write In This Space)
City, State, ZIP Code
5. APPLICANT'S ADDRESS
2. SEX OF APPLICANT 3. APPLICANT'S DATE OF BIRTH
8. PLEASE PROVIDE THE NAME, ADDRESS, AND PHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
Primary:
Routing or Transit Number
Checking
Account Type
7. DIRECT DEPOSIT (Attach a voided personal check or provide the following information. Direct Deposit is not available for VEAP)
PART III - TYPE AND PROGRAM OF EDUCATION OR TRAINING
YearDay
Apt./Unit Number
Secondary:
Number and Street
10A. TYPE OF EDUCATION OR TRAINING (See instructions for additional information)
9A. Chapter 33 - Post-9/11 GI Bill (Complete 9F if you are eligible for chapter 30, chapter 1606, or chapter 1607)
9B. Chapter 30 - Montgomery GI Bill Educational Assistance Program (MGIB)
9C. Chapter 1606 - Montgomery GI Bill - Selected Reserve Educational Assistance Program (MGIB-SR)
B. ADDRESS C. PHONE NUMBERA. NAME
9D. Chapter 1607 - Reserve Educational Assistance Program (REAP)
PART I - APPLICANT INFORMATION
6B. APPLICANT'S E-MAIL ADDRESS (If applicable)
LICENSING OR CERTIFICATION TEST REIMBURSEMENT
(MCSE, CCNA, EMT, NCLEX, ETC.)
CORRESPONDENCE
COLLEGE OR OTHER SCHOOL (Including on-line courses)
TUITION ASSISTANCE TOP-UP
(Chapter 30 & 33 only)
NATIONAL TEST REIMBURSEMENT (SAT, CLEP, ETC.)
VOCATIONAL FLIGHT TRAINING
APPRENTICESHIP OR ON-THE-JOB
6A. APPLICANT'S TELEPHONE NUMBERS (Include Area Code)
Month
9E. Chapter 32 or Section 903 - Post-Vietnam Era Veterans' Educational Assistance Program (VEAP)
9F. Chapter 33 Election (Complete only if this is your first request for chapter 33 and you are eligible for one of the benefits listed below)
I elect to receive chapter 33 education benefits in lieu of the education benefit checked below, effective .
I understand that my election is irrevocable and may not be changed. (Check only one)
Chapter 30 - Montgomery GI Bill Educational Assistance Program (MGIB)
By electing Chapter 33, I acknowledge that I understand the following:
• I may not receive more than a total of 48 months of benefits under two or more programs.
• If electing chapter 33 in lieu of chapter 30, my months of entitlement under chapter 33 will be limited to the number
of months of entitlement remaining under chapter 30 on the effective date of my election. However, if I completely
exhaust my entitlement under chapter 30 before the effective date of my chapter 33 election, I may receive up to 12
additional months of benefits under chapter 33.
• My election is irrevocable and may not be changed.
Chapter 1607 - Reserve Educational Assistance Program (REAP)
Chapter 1606 - Montgomery GI Bill - Selected Reserve Educational Assistance Program (MGIB-SR)
(date)
PAGE 2 OF 4
10B. PROVIDE THE FULL NAME AND ADDRESS OF THE SCHOOL, IF KNOWN (Skip this item if you are only applying for National Test Reimbursement, Licensing
and Certification Test Reimbursement, or Tuition Assistance Top-Up)
10C. PLEASE SPECIFY YOUR EDUCATIONAL OR CAREER OBJECTIVE, IF KNOWN (e.g. Bachelor of Arts in Accounting, welding certificate, police officer, etc.)
NOYES
PART V - EDUCATION AND EMPLOYMENT INFORMATION
NOTE: It will help VA process your claim if you send a copy of the following:
DD Form 214 (Member 4) for all periods of active duty service (excluding active duty for training)
DD Form 2384, Notice of Basic Eligibility (NOBE) if applying for Chapter 1606
Copies of orders if activated from the guard/reserves
14B. DO YOU HOLD ANY FAA FLIGHT CERTIFICATES? (If "Yes," specify each
certificate in Part IX, Remarks)
SOCIAL SECURITY NUMBER OF APPLICANT
(Please provide a copy of your DD Form 214 (Member 4) when issued)
14C. EDUCATION AFTER HIGH SCHOOL (Including apprenticeship, on-the-job training, and flight training)
11. ARE YOU NOW ON ACTIVE DUTY? (Do not check "Yes" if you are currently on drilling status in the the Selected Reserve, or if you
are on active duty for training)
NOYES
C. SERVICE COMPONENT (USN,
USAF, USAR, ARNG, ETC.)
B. DATE SEPARATED
D. SERVICE STATUS (Active duty,
drilling reservist, IRR, etc.)
E. WERE YOU INVOLUNTARILY CALLED TO
ACTIVE DUTY FOR THIS PERIOD?
A. DATE ENTERED
PART IV - SERVICE INFORMATION
DATE:
12. ARE YOU NOW ON TERMINAL LEAVE JUST BEFORE DISCHARGE?
14A. DID YOU RECEIVE A HIGH SCHOOL DIPLOMA OR HIGH SCHOOL
EQUIVALENCY CERTIFICATE? (If "Yes" provide date)
NOYES
13. PLEASE COMPLETE THE FOLLOWING FOR EACH PERIOD OF MILITARY SERVICE
NOYES
DEGREE, DIPLOMA,
OR CERTIFICATE
RECEIVED
DATES OF TRAINING
TOFROM
MAJOR FIELD OR COURSE OF STUDY
NAME AND LOCATION OF
COLLEGE OR OTHER
TRAINING PROVIDER
NUMBER AND TYPE OF
HOURS (Semester,
Quarter, or Clock)
8/15/2007
(EXAMPLE)
USMC
1/18/2005
9/26/2000 9/24/2004
8/14/2007
Present
DRILLINGUSMCR
ACTIVE DUTY YES
ACTIVE DUTY
N/A
NO
USMC
VA FORM 22-1990, MAY 2009
18. WERE YOU COMMISSIONED AS THE RESULT OF A SENIOR ROTC (Reserve Officers Training Corps)
SCHOLARSHIP? If you received your commission through a non-scholarship program, check "No." If
"Yes," provide the date of your commission and the amount of your scholarship for each school year you
were in the Senior ROTC program. Don't report your monthly subsistence allowance (stipend).
ACTIVE DUTY KICKER
Date of Commission
21. FOR ACTIVE DUTY CLAIMANTS ONLY: ARE YOU RECEIVING, OR DO YOU ANTICIPATE RECEIVING, ANY MONEY
(INCLUDING BUT NOT LIMITED TO FEDERAL TUITION ASSISTANCE) FROM THE ARMED FORCES OR PUBLIC
HEALTH SERVICE FOR THE COURSE FOR WHICH YOU HAVE APPLIED TO THE VA FOR EDUCATION BENEFITS?
IF YOU RECEIVE SUCH BENEFITS DURING ANY PART OF YOUR TRAINING, CHECK "YES." NOTE: IF YOU ARE
ONLY APPLYING FOR TUITION ASSISTANCE TOP-UP, CHECK NO IN THIS ITEM.
17. IF YOU GRADUATED FROM A MILITARY SERVICE ACADEMY, SPECIFY THE YEAR YOU GRADUATED AND
RECEIVED YOUR COMMISSION.
19. ARE YOU CURRENTLY PARTICIPATING IN A SENIOR ROTC SCHOLARSHIP PROGRAM THAT PAYS FOR YOUR
TUITION, FEES, BOOKS AND SUPPLIES UNDER SECTION 2107 OF TITLE 10, U.S. CODE?
Graduation Year
16. DO YOU QUALIFY FOR A KICKER (sometimes called a "College Fund") BASED ON YOUR MILITARY SERVICE?
(Kickers are additional amounts contributed by DOD to an education fund). If you qualify for a kicker, it will help
VA process your claim if you submit a copy of the kicker contract. Reserve kicker contracts must include the
amount and effective date.
Scholarship Amounts:
Year:
Amount:
Year:
Amount:
Year:
Year:
Year:
Amount:
Amount:
Amount:
14D. EMPLOYMENT (Only complete if you held a license or journeyman rating to practice a profession)
LICENSE OR RATINGNUMBERS OF MONTHS WORKEDEMPLOYMENT
AFTER MILITARY SERVICE
PRINCIPAL OCCUPATION
BEFORE MILITARY SERVICE
PART VI - ENTITLEMENT TO AND USAGE OF ADDITIONAL TYPES OF ASSISTANCE
NO
NO
RESERVE KICKER
YES
YES
NOYES
NOYES
15. DID YOU MAKE ADDITIONAL CONTRIBUTIONS (UP TO $600.00) TO INCREASE THE AMOUNT OF YOUR MONTHLY
BENEFITS? IF "YES," IT WILL HELP VA PROCESS YOUR CLAIM IF YOU SUBMIT ANY EVIDENCE YOU HAVE TO
SUPPORT YOUR CLAIM (e.g., cash collection voucher, leave and earnings statement(s), receipt voucher, etc.)
22. FOR CIVILIAN EMPLOYEES OF THE U.S. GOVERNMENT ONLY: ARE YOU RECEIVING, OR DO YOU ANTICIPATE
RECEIVING, ANY MONEY (INCLUDING, BUT NOT LIMITED TO, THE GOVERNMENT EMPLOYEES TRAINING ACT)
FROM YOUR AGENCY FOR THE SAME PERIOD FOR WHICH YOU HAVE APPLIED TO THE VA FOR EDUCATION
BENEFITS? IF YOU WILL RECEIVE SUCH BENEFITS DURING ANY PART OF YOUR TRAINING, CHECK "YES."
NOYES
20. IF YOU HAD A PERIOD OF ACTIVE DUTY THAT THE DEPARTMENT OF DEFENSE COUNTS FOR PURPOSES OF
REPAYING AN EDUCATION LOAN, CHECK "YES". SHOW THE PERIOD OF ACTIVE DUTY THAT THE MILITARY
CONSIDERS AS BEING USED FOR THE PURPOSES OF REPAYING THIS EDUCATION LOAN IN PART IX "REMARKS".
NOYES
NOYES
NOYES
SOCIAL SECURITY NUMBER OF APPLICANT
PAGE 3 OF 4
VA FORM 22-1990, MAY 2009
NOTE : Only complete this section if you have military service before January 1, 1977 (or delayed entry before January 2, 1978). See instructions.
PAGE 4 OF 4
NOTE: The most current information on VA education benefits is available online at www.gibill.va.gov
If you would like to receive a printed pamphlet check here.
25A. SIGNATURE OF APPLICANT (DO NOT PRINT)
PART VIII - MARITAL AND DEPENDENCY STATUS
25B. DATE SIGNED
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief. If on active duty, I also certify
that I have consulted with an Education Service Officer (ESO) regarding my education program.
PART X - CERTIFICATION AND SIGNATURE OF APPLICANT
NOYES
23. DO YOU HAVE ANY CHILDREN WHO ARE UNDER AGE 18, OR OVER 18 BUT UNDER AGE 23, NOT MARRIED AND ATTENDING SCHOOL, OR OF
ANY AGE PERMANENTLY HELPLESS FOR MENTAL OR PHYSICAL REASONS?
SOCIAL SECURITY NUMBER OF APPLICANT
PART IX - REMARKS
(If more space is needed, please attach a separate sheet of paper. Be sure to include your name and social security number on each sheet)
NOYES
22. ARE YOU MARRIED?
PART VII - INFORMATION ON VA EDUCATION BENEFITS
NOYES
APPLICATION SUBMISSION REMINDERS
Did you remember to ........
Write your social security number on each page?
Write your complete mailing address?
Attach all supporting documents (e.g. voided check, orders, DD214, kicker contract, NOBE, cash
collection voucher, etc.)?
IF SO, PLEASE SIGN AND DATE THE APPLICATION BELOW
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.
24. DO YOU HAVE A PARENT WHO IS DEPENDENT UPON YOU FOR FINANCIAL SUPPORT?
VA FORM 22-1990, MAY 2009
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APPLICATION FOR VA EDUCATION BENEFITS (VA FORM 22-1990) (Community College of Allegheny County)

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