Fillable DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS (Under Provisions (University of California, Merced)

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DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS (Under Provisions (University of California, Merced)

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ACCOUNT NUMBER
22-5490
DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(Under Provisions of chapters 33 and 35, of title 38,U.S.C.)
VA FORM
JUL 2012
6. TELEPHONE NUMBER(S)
(Including Area Code)
OMB Approved No. 2900-0098
Respondent Burden: 45 minutes
9. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
2. SEX OF APPLICANT
4. NAME
(FIRST-MIDDLE-LAST)
ROUTING OR TRANSIT NUMBER
7. E-MAIL ADDRESS
(If applicable)
17. DO YOU OR THE QUALIFYING INDIVIDUAL ON WHOSE ACCOUNT YOU ARE CLAIMING BENEFITS HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
PART I - APPLICANT INFORMATION
3. DATE OF BIRTH
5. CURRENT MAILING ADDRESS
(Number and street or rural route, city or P.O., State and ZIP Code)
1. SOCIAL SECURITY NUMBER
11. SOCIAL SECURITY NUMBER OR VA FILE NUMBER
14. DATE OF DEATH OR DATE LISTED AS
MISSING IN ACTION OR P.O.W.
PART II - QUALIFYING INDIVIDUAL INFORMATION
PART III - BENEFIT AND TYPE OF EDUCATION OR TRAINING
VA DATE STAMP
(For VA Use Only)
12. BRANCH OF SERVICE
SPOUSE SURVIVING SPOUSE
SECONDARY
SAVINGS
YES NO
15. IS QUALIFYING INDIVIDUAL CURRENTLY ON ACTIVE DUTY?
SUPERSEDES VA FORM 22-5490, OCT 2011,
WHICH WILL NOT BE USED.
FEMALE
INTERNET VERSION AVAILABLE - You may complete and submit your application online at: www.gibill.va.gov
10. NAME OF INDIVIDUAL ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (FIRST- MIDDLE -LAST)
MALE
8. DIRECT DEPOSIT
(Attach a voided personal check or provide the following information. Direct Deposit is not available for DEA benefit payments)
ADOPTED CHILD
PRIMARY
STEPCHILDCHILD
16. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL
13. DATE OF BIRTH
CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY SERGEANT JOHN DAVID FRY
SCHOLARSHIP (FRY SCHOLARSHIP)
ACCOUNT TYPE
CHECKING
C. TELEPHONE NUMBER
(Include Area Code)
A. NAME B. ADDRESS
YES NO
COLLEGE OR OTHER SCHOOL
CHAPTER 35 - SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE
PROGRAM (DEA)
APPRENTICESHIP OR OTHER ON-THE-JOB TRAINING
FARM COOPERATIVE
NATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDIT
CORRESPONDENCE COURSE
(DEA Children not eligible)
LICENSING OR CERTIFICATION TEST
PAGE 1
FLIGHT TRAINING (Fry Scholarship only)
18A. TYPE OF BENEFIT
18B. TYPE OF TRAINING
IMPORTANT: You may not receive payments of Dependency and Indemnity Compensation (DIC) or Pension and you may not be claimed as a
dependent in a compensation claim while receiving Survivors' and Dependents' Educational Assistance
(DEA). CAREFULLY READ THE
INSTRUCTIONS BEFORE COMPLETING THIS ELECTION BLOCK. YOU ARE STRONGLY ENCOURAGED TO DISCUSS YOUR ELECTION WITH A
VA COUNSELOR
.
(If "Yes," please provide date of remarriage)
22. IF YOU ARE THE SPOUSE OF A DISABLED VETERAN, IS A DIVORCE OR ANNULMENT PENDING?
PART VI - APPLICANT'S MILITARY SERVICE INFORMATION
(Note: Chapter 35 benefits are not payable while an eligible person is on active duty)
29. SOCIAL SECURITY NUMBER OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS
PART IV - DEA APPLICANT AND ELECTION INFORMATION
(Fry Scholarship Applicants, Skip to Part V)
25. IF YOU ARE THE SURVIVING SPOUSE OF A DECEASED VETERAN, HAVE YOU REMARRIED SINCE HIS OR HER DEATH?
YES NO
21. DATE YOU WILL BEGIN SCHOOL OR TRAINING
19. NAME AND ADDRESS OF SCHOOL OR TRAINING FACILITY
(Number and street or rural route, city or P.O., State and ZIP Code)
20. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE, IF KNOWN (e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer )
SOCIAL SECURITY NUMBER OF APPLICANT
24. ARE YOU A HANDICAPPED CHILD, SPOUSE, OR SURVIVING
SPOUSE SEEKING SPECIALIZED VOCATIONAL TRAINING?
23. ARE YOU A HANDICAPPED CHILD (14 YEARS OR OLDER), SPOUSE, OR
SURVIVING SPOUSE SEEKING SPECIAL RESTORATIVE TRAINING?
YES
YES
NO NO
SECTION II - ELECTION (CHILD APPLICANTS ONLY)
YES NO
SECTION I - APPLICANT INFORMATION
26. I CERTIFY that I understand the effects of an election to receive DEA benefits and I elect to receive such benefits on the following date:
G. OTHER (Specify benefit(s)
D. VETERANS EDUCATION ASSISTANCE BASED ON YOUR OWN SERVICE SPECIFY BENEFIT(S):
B. DEPENDENTS' INDEMNITY COMPENSATION
(DIC)
E. VETERANS EDUCATION ASSISTANCE BASED ON SOMEONE ELSE'S SERVICE
SPECIFY BENEFIT(S) BY CHECKING APPLICABLE BOX BELOW AND COMPLETE ITEMS 28 AND 29
TRANSFERRED ENTITLEMENT
C. VOCATIONAL REHABILITATION BENEFITS
(Chapter 31)
IMPORTANT: Complete Items 28 and 29 only if you checked block "E" in Item 27
CHAPTER 35 - SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE PROGRAM (DEA)
CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY SERGEANT DAVID FRY SCHOLARSHIP
A. DISABILITY COMPENSATION OR PENSION
F. NONE
27. PRIOR TO THIS APPLICATION, HAVE YOU EVER APPLIED FOR OR RECEIVED ANY OF THE FOLLOWING VA BENEFITS?
(Check all appropriate boxes)
30. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES? (If "No," skip to Part VII)
PART V - APPLICATION HISTORY
31. INFORMATION ABOUT YOUR PERIOD(S) OF ACTIVE DUTY
28. NAME OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS (First, Middle, Last)
YES NO
PAGE 2
D. CHARACTER OF DISCHARGEA. DATE ENTERED ACTIVE DUTY
B. DATE SEPARATED FROM
ACTIVE DUTY
C. BRANCH OF SERVICE OR
RESERVE OR GUARD
COMPONENT
YEAR
MONTH
DAY
YEAR
MONTH
DAY
YEAR
MONTH
DAY
VA FORM 22-5490, JUL 2012
35. CURRENT AND PAST EMPLOYMENT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.
DID YOU REMEMBER TO:
PART VII - EDUCATION, TRAINING, AND EMPLOYMENT
36B. SOURCE OF EDUCATIONAL ASSISTANCE FROM GOVERNMENT
EMPLOYMENT
39B. DATE SIGNED
37. REMARKS
(If more space is needed, please attach a separate sheet of paper. Be sure to include name and social security number on each sheet)
PENALTY: Willfully 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.
SIGN HERE
IN INK
PART IX - CERTIFICATION AND SIGNATURE OF APPLICANT
33. DATE
PART VIII - REMARKS, REMINDERS AND VA EDUCATION BENEFITS PAMPHLET
34B. NAME AND
LOCATION OF SCHOOL
(City and State)
TO
SECTION II - EMPLOYMENT
32. CHECK THE APPROPRIATE BOX AND ENTER THE DATE IN ITEM 33
34C. DATES OF TRAINING
GRADUATED FROM HIGH SCHOOL
EXPECT TO GRADUATE FROM HIGH SCHOOL
NEVER ATTENDED HIGH SCHOOL
AWARDED GED
FROM
34E. DEGREE,
DIPLOMA, OR
CERTIFICATE
RECEIVED
OTHER
(Specify)
DISCONTINUED HIGH SCHOOL
34D. NUMBER OF
SEMESTER,
QUARTER, OR CLOCK
HOURS COMPLETED
34F. MAJOR FIELD OR
COURSE OF STUDY
34A.
TYPE OF
SCHOOL
HIGH SCHOOL
COLLEGE
VOCATIONAL
OR TRADE
SECTION I - REMARKS
38. THE MOST CURRENT INFORMATION ON VA EDUCATION BENEFITS IS AVAILABLE ONLINE AT www.gibill.va.gov IF YOU WOULD LIKE A COPY OF THE VA
EDUCATION BENEFITS PAMPHLET PLEASE CHECK THE BOX.
D. LICENSE OR RATING
NOTE: Complete Item 36 only if you are a civilian employee of the U.S. Government
A. EMPLOYER B. JOB TITLE
C. NUMBER OF MONTHS
EMPLOYED
SECTION III - VA EDUCATION BENEFITS PAMPHLET
39A. SIGNATURE OF APPLICANT (DO NOT PRINT)
SECTION II - REMINDERS
YES
NO
36A. DO YOU EXPECT TO RECEIVE FUNDS FROM YOUR AGENCY OR
DEPARTMENT FOR THE SAME COURSES FOR WHICH YOU EXPECT TO
RECEIVE VA EDUCATIONAL ASSISTANCE?
(If "Yes," complete Item 36B)
PAGE 3
SECTION I - EDUCATION & TRAINING
SOCIAL SECURITY NUMBER OF APPLICANT
WRITE YOUR SOCIAL SECURITY NUMBER ON EACH PAGE
WRITE YOUR COMPLETE MAILING ADDRESS
ATTACH SUPPORTING DOCUMENTS (e.g., birth certificate, marriage license, DD214, etc.)
©
VA FORM 22-5490, JUL 2012
Use this form to apply for educational assistance under the following benefit programs:
Survivors' and Dependents' Educational Assistance Program (DEA) (chapter 35 of title 38, U.S. Code)
Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship (Fry Scholarship)
(chapter 33 of title 38, U.S. Code)
(Please detach at perforation and retain this information for future reference)
INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(VA FORM 22-5490)
VA FORM
JUL 2012
22-5490
SUPERSEDES VA FORM 22-5490, OCT 2011,
WHICH WILL NOT BE USED.
Do not use this form to apply for Veterans' education assistance based on your own service (chapters 30, 32, 33, 1606, or 1607) or
vocational rehabilitation benefits (chapter 31). To apply for veterans' education assistance based on your own service, use VA Form
22-1990. To apply for vocational rehabilitation benefits, use VA Form 28-1900.
INTERNET VERSION AVAILABLE - You may complete and submit this application on-line at www.gibill.va.gov. Click on "GI Bill:
Apply for Benefits."
VA VOCATIONAL AND EDUCATIONAL COUNSELING HELP AVAILABLE - VA offers a wide range of services to assist you in
planning your educational and/or career goals. Services include educational and vocational guidance and testing to develop a greater
understanding of your skills, talents, and interests. For more information on VA counseling, call VA toll-free at 1-888-GIBILL-1
(1-888-442-4551) or if you use the Telecommunications Device for the Deaf (TDD), the Federal Relay number is 711.
NOTE: The number on the instructions match the item numbers on this application. Items not mentioned are self-explanatory.
ITEM 17. You will not be eligible to receive benefits for any period for which you or the qualifying individual on whose account you are
claiming benefits has an outstanding felony warrant. Any benefits paid to you for such period will result in an overpayment and be
subject to collection.
ITEM 18.
18A. Select the benefit for which you are applying.
To qualify for Survivors' and Dependents' Educational Assistance (DEA) you must be either -
(1) The spouse or child of a veteran who is permanently and totally disabled as a result of a service-connected disability.
(2) The spouse or child of an individual on active duty who has been listed as missing in action, captured in line of duty
by hostile force, forcibly detained or interned in line of duty by hostile force, or forcibly detained or interned in line of
duty by foreign government or power for more than 90 days.
(3) The surviving spouse or child of a veteran who died of a service-connected disability or who dies while a
service- connected disability was rated permanent and total in nature.
(4) The spouse or child of an individual on active duty for which the evidence shows that the individual is hospitalized
for receiving outpatient medical care services or treatment; has a total disability permanent in nature incurred or
aggravated in the line of duty in the active military, naval, or air service; and the serviceperson is likely to be
discharged or released from such service for such disability.
Eligibility for DEA will be terminated in the event that VA determines that the individual on whose account benefits are claimed is no
longer totally disabled or VA is notified that the individual is no longer listed as captured, missing in action, or forcibly detained.
18B. To qualify for the Fry Scholarship, you must be the child of an individual who after September 10, 2001, died in the line of duty
while serving on active duty as a member of the Armed Forces.
18A. & 18B. Types of education or training programs are self-explanatory, except for the following -
"Licensing or Certification Test." 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.
"National Admission Exam or National Exam for Credit." Individuals eligible to receive benefits under the Survivors' and Dependents'
Educational Assistance program may be reimbursed for the cost of approved tests for admission to or credit at institutions of higher
learning.
"Correspondence." Only spouses and surviving spouses eligible for the Survivors' and Dependents' Educational Assistance program
may receive benefits for correspondence training. Payments for correspondence courses are made quarterly after VA receives a
certification showing the number of lessons completed. For more information on correspondence courses, please visit our website at
www.gibill.va.gov.
"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.
INFORMATION AND INSTRUCTIONS (Continued)
ITEMS 23 and 24. Any individual eligible under the Survivors' and Dependents' Educational Assistance program may receive Special
Restorative Training or Specialized Vocational Training if a VA counselor determines that a specialized program is needed to overcome
the effects of a physical or mental handicap. To be eligible for receipt of specialized training, the disability must prevent you from
pursuing an educational program. Examples of Special Restorative Training include speech and voice correction, language retraining,
lip reading, and Braille reading and writing. Specialized Vocational Training consists of specialized courses leading to a suitable
vocational objective.
ITEM 26. Your election to receive Survivors' and Dependents' Educational Assistance (DEA) is final and cannot be changed. This
means that payments of compensation, pension, and Dependents' Indemnity Compensation (DIC) will be terminated upon issuance of
a DEA benefit payment. If you are planning to pursue a program of education for more than 45 months, you should consider deferring
receipt of DEA benefits. We strongly recommend that you discuss your education or training plans with a VA counselor before making a
decision. If you decide to elect benefits under DEA, indicate the date from which you wish your DEA payments to begin.
Step 3: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.
ADDITIONAL HELP COMPLETING APPLICATION
(B) If you have not selected a school or training establishment:
If you need additional help completing this application or you want information about our work-study program, call VA toll-
free at 1-888-GIBILL-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 more information about education assistance from our education Internet site at
www.gibill.va.gov.
Step 1: Mail the completed application to the VA Regional Processing Office for the region of your home address. Check next
page for the post office box address for these offices.
(A) If you have selected a school or training establishment:
Step 2: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.
Step 1: Mail the completed application to the VA Regional Processing Office for the region of that school's physical address.
See reverse 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 submit your enrollment information using VA Form 22-1999, Enrollment Certification, or its electronic version.
HOW TO FILE YOUR CLAIM
Be sure to do the following:
VA FORM 22-5490, JUL 2012
Western Region:
VA Regional Office
P. O. Box 8888
Muskogee, OK 74402-8888
SERVES THE FOLLOWING STATES
Eastern Region:
VA Regional Office
P. O. Box 4616
Buffalo, NY 14240-4616
CT DCDE
ME
MD NHMA NJ
NY RIPA VT
VA
Foreign
Schools
AK ARAL AZ
Philippines
OR
CA IDHI LA
MS
WATX
OK
SERVES THE FOLLOWING STATES
NM NV
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., awards of benefits) 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 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. 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 in effect prior to January 1, 1975, and still in effect. The requested
information is considered relevant and necessary to determine the maximum benefits allowable under the law. While you do not have to respond,
VA cannot process your claim for benefits 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 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 U.S.C. allows
us to ask for this information. We estimate that you will need an average of 45 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 (1-888-442-4551) to get information on where to
send comments or suggestions about this form.
Central Region:
VA Regional Office
P. O. Box 66830
St. Louis, MO 63166-6830
CO ILIA
IN
KS MIKY MN
MO NEMT ND
OH
WV
SD
SERVES THE FOLLOWING STATES
TN
UT
Guam APO/FPO AP
VA FORM 22-5490, JUL 2012
WI
WY
Southern Region:
VA Regional Office
P. O. Box 100022
Decatur, GA 30031-7022
SERVES THE FOLLOWING STATES
FL
GA
PR
SC
US Virgin
Islands
NC
APO/FPO AA
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DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS (Under Provisions (University of California, Merced)

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