APPLICATION FOR WORK-STUDY ALLOWANCE
PART I - IDENTIFICATION INFORMATION
VA FORM
JUL 2012
22-8691
OMB Approved No. 2900-0209
Respondent Burden: 15 minutes
1. NAME OF APPLICANT (First, Middle, Last)
EXISTING STOCKS OF VA FORM 22-8691, MAR 2009,
WILL NOT BE USED.
PRIVACY ACT INFORMATION: VA will not disclose information collected by this information collection to any source other than what has been authorized by the Privacy Act of 1974 or
Title 38 Code of Federal Regulations 1.576 for routine uses as identified in VA's system of records, 58 VA 21/22/28, Compensation, Pension, Education and Vocational Rehabilitation Records -
VA as published in the Federal Register at http://www.rms.oit.va.gov/SOR_Records/58VA21_22.asp. An example of a 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 benefits". We
cannot pay you any work-study benefits until we receive this information (38 U.S.C. 3485). Your responses are confidential (38 U.S.C. 5701). Any information provided by applicants may be
subject to verification through computer matching programs with other agencies.
Respondent Burden: We need this information to determine your eligibility for VA work-study benefits. 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 the 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.htm#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.
15. SIGNATURE OF APPLICANT
(Do not print)
13. SPECIFY THE DAYS AND HOURS DURING THE WEEK YOU ARE AVAILABLE TO WORK
10. HAVE YOU EVER PARTICIPATED IN THE VA WORK-STUDY
PROGRAM BEFORE? (If "YES," please state where you worked)
11. WORK SITE PREFERENCE (Tell us the school, VA facility or other government
facility where you would prefer to do VA related work. Be specific as many facilities
have the same name or perform the same services in different locations or cities.)
PART III - WORK STUDY INFORMATION
16. DATE SIGNED
9. ADVANCE PAYMENT - DO YOU WANT AN ADVANCE PAYMENT? (See instructions for information on advance payment on reverse under
"How Much Can I Earn?")
WHEN AVAILABLE (From & To)
(X)
MONDAY
FEMALE
FRIDAY
DAYS
TUESDAY
WEDNESDAY
THURSDAY
5. EDUCATION BENEFIT RECEIVING
8. NEXT ENROLLMENT PERIOD YOU PLAN TO ATTEND
2. MAILING ADDRESS OF APPLICANT
(Number, and street or rural route, city or
P.O., State and 9 digit ZIP Code)
MALE
B. ENDING DATE
(Month, Day, Year)
A. BEGINNING DATE
(Month, Day, Year)
A. BEGINNING DATE
(Month, Day, Year)
B. ENDING DATE
(Month, Day, Year)
7. CURRENT ENROLLMENT INFORMATION
3A. VA FILE NUMBER
(For chapter 35, enter the veteran's file number.
Be sure to include the suffix indicator. For dependent's transfer of
entitlement cases, enter the file number of the person who transferred
entitlement to you)
3B. SOCIAL SECURITY NUMBER (If not shown in Item 3A)
3C. DATE OF BIRTH OF APPLICANT (Month, Day, Year)
3D. SEX OF APPLICANT
4A. TELEPHONE NUMBER
(Include Area Code)
TRANSFER OF ENTITLEMENT
PROGRAM
(Parent or Spouse
entitled to benefits)
CHAPTER 35 (Dependents Educational Assistance)CHAPTER 30 (Montgomery GI Bill - Active Duty)
CHAPTER 32 (Veterans Educational Assistance Program)
PART II - SCHOOL INFORMATION
CHAPTER 1607 (Reserve Educational Assistance Program)
6A. NAME AND COMPLETE ADDRESS OF SCHOOL 6B. CURRENT ACADEMIC OR TRAINING PROGRAM
NO
12. WORK EXPERIENCE (Tell us about the jobs you had before,
other than VA work-study jobs. Please be as specific as possible.
If you have no work experience, place "NONE" in this space. If
needed, attach a separate sheet with your work-history)
YES
YES NO
14. QUALIFICATIONS
(Tell us about any special qualifications you have based on your education or work experience. Include any experience in information
technology. Also, tell us what kinds of jobs interest you. If needed, attach a separate sheet with this information)
4B. PLEASE PROVIDE THE HOURS THAT VA CAN REACH YOU
EVENINGDAYTIME
CHAPTER 31
(Vocational Rehabilitation) CHAPTER 1606 (Montgomery GI Bill - Selected Reserve)
CHAPTER 33 (Post- 9/11 GI Bill)
