Fillable DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS (Under Provisions (Piedmont Community College)

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DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS (Under Provisions (Piedmont Community College)

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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
JUN 2017
6. TELEPHONE NUMBER(S)
(Including Area Code)
OMB Approved No. 2900-0098
Respondent Burden: 45 minutes
Expiration Date: 9/30/2018
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 name, middle initial, last name)
ROUTING OR TRANSIT NUMBER
7. E-MAIL ADDRESS
16. DO YOU (APPLICANT) OR THE QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) 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
SECONDARY
SAVINGS
YES NO
15. IS QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON ACTIVE
DUTY?
SUPERSEDES VA FORM 22-5490, DEC 2016,
WHICH WILL NOT BE USED.
FEMALE
INTERNET VERSION AVAILABLE - You may complete and submit your application online at: www.benefits.va.gov/gibill.
10. NAME OF QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (First name, middle initial, last name)
MALE
8. DIRECT DEPOSIT (Attach a voided personal check or provide the following information. See instructions for additional information.)
PRIMARY
13. DATE OF BIRTH
ACCOUNT TYPE
CHECKING
C. TELEPHONE NUMBER
(Include Area Code)
A. NAME B. ADDRESS
YES NO
COLLEGE OR OTHER SCHOOL
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)
17B. TYPE OF EDUCATION OR TRAINING
17A. DATE YOU WILL BEGIN SCHOOL OR TRAINING
17D. ARE YOU SEEKING SPECIAL VOCATIONAL TRAINING DUE TO A
DISABILITY THAT PREVENTS YOU FROM PURSUING AN EDUCATIONAL
PROGRAM?
YES NO
17C. ARE YOU SEEKING SPECIAL RESTORATIVE TRAINING DUE TO A DISABILITY
THAT PREVENTS YOU FROM PURSUING AN EDUCATIONAL PROGRAM?
YES NO
SOCIAL SECURITY NUMBER OF APPLICANT
26. I CERTIFY THAT I UNDERSTAND THE EFFECTS THAT THIS ELECTION TO RECEIVE DEA OR FRY SCHOLARSHIP BENEFITS WILL HAVE ON MY ELIGIBILITY TO
RECEIVE DIC, AND I ELECT TO RECEIVE SUCH EDUCATION BENEFITS ON THE FOLLOWING DATE:
(If "Yes," please provide date of remarriage)
22. IS A DIVORCE OR ANNULMENT PENDING TO THE QUALIFYING INDIVIDUAL?
PART IV - BENEFIT ELECTION
23. IF YOU ARE THE SURVIVING SPOUSE, HAVE YOU REMARRIED?
19. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE, IF KNOWN
(e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer )
20. WOULD YOU LIKE TO RECEIVE VOCATIONAL AND EDUCATIONAL COUNSELING? (Please see Item 20 in the instruction section for more details about vocational
and educational counseling)
YES NO
YES NO
SECTION I - SPOUSE/SURVIVING SPOUSE
YES NO
PAGE 2
VA FORM 22-5490, JUN 2017
18B. IN WHAT STATE DO YOU ANTICIPATE LIVING WHILE PARTICIPATING IN THIS TRAINING
(You must notify us immediately if the state in which you live changes
from the state indicated below)
GIVE TWO-LETTER POSTAL ABBREVIATION CODE
IMPORTANT: For help completing this section, please see the attached instructions page or click on the "Summary of VA Education Benefits" link at
www.benefits.va.gov to compare various benefits and eligibility criteria. For general information, visit our website at www.benefits.va.gov/gibill.
21. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL (Check only one)
SPOUSE/SURVIVING SPOUSE
(Please complete only Section I below,
and then proceed to Part V)
CHILD/STEPCHILD/ADOPTED CHILD
(Please complete only Section II below,
and then proceed to Part V)
24. PLEASE SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW
A. I AM APPLYING FOR CHAPTER 35 - DEA B. I AM APPLYING FOR CHAPTER 33 - FRY SCHOLARSHIP
IMPORTANT: If you are eligible for Chapter 35 Survivors' and Dependents' Educational Assistance Program (DEA) and eligible for Chapter 33
Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship (Fry Scholarship), you must relinquish entitlement to the benefit that you
are not applying for (even if entitlement arises from separate events). You cannot retain eligibility for both programs simultaneously. By
checking the box below, you agree and understand that you are making an irrevocable election to receive the selected benefit and your election may
not be changed. PLEASE CAREFULLY READ THE INFORMATION AND INSTRUCTIONS PAGE BEFORE MAKING A SELECTION.
By checking this box I acknowledge that I understand this
election is irrevocable and may not be changed.
By checking this box I acknowledge that I understand this
election is irrevocable and may not be changed.
SECTION II - CHILD/STEPCHILD/ADOPTED CHILD
25. PLEASE SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW
A. I AM APPLYING FOR CHAPTER 35 - DEA B. I AM APPLYING FOR CHAPTER 33 - FRY SCHOLARSHIP
IMPORTANT: If you are eligible for Chapter 35 Survivors' and Dependents' Educational Assistance Program (DEA) and eligible for Chapter 33
Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship (Fry Scholarship), you must relinquish entitlement to the benefit that you
are not applying for (but only with regards to the entitlement arising from the same events). You cannot retain eligibility for both programs
based on the same event. By checking the box below, you agree and understand that you are making an irrevocable election to receive the selected
benefit and your election may not be changed. PLEASE CAREFULLY READ THE INFORMATION AND INSTRUCTIONS PAGE BEFORE
MAKING A SELECTION.
By checking this box I acknowledge that I understand this
election is irrevocable and may not be changed.
By checking this box I acknowledge that I understand this
election is irrevocable and may not be changed.
IMPORTANT: While receiving DEA or FRY Scholarship benefits 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.
CAREFULLY READ THE INSTRUCTIONS BEFORE
COMPLETING THE ELECTION BLOCK BELOW. YOU ARE STRONGLY ENCOURAGED TO DISCUSS YOUR ELECTION WITH A VA COUNSELOR
.
(If "Yes," please provide date of election)
YES NO
18A. NAME AND ADDRESS OF SCHOOL OR TRAINING FACILITY (Number and street or rural route, city or P.O., State and ZIP Code)
34C. DATES OF TRAINING
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
YES NO
SOCIAL SECURITY NUMBER OF APPLICANT
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)
PAGE 3
D. CHARACTER OF DISCHARGE
A. DATE ENTERED ACTIVE DUTY
B. DATE SEPARATED
FROM ACTIVE DUTY
C. BRANCH OF SERVICE OR
RESERVE OR GUARD COMPONENT
VA FORM 22-5490, JUN 2017
PART VII - EDUCATION, TRAINING, AND EMPLOYMENT
33. DATE
34B. NAME AND LOCATION
OF SCHOOL
(City and State)
TO
32. CHECK THE APPROPRIATE BOX AND ENTER THE DATE IN ITEM 33
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 - EDUCATION & TRAINING
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)
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:
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
PART VIII - REMARKS, REMINDERS AND VA EDUCATION BENEFITS PAMPHLET
SECTION II - EMPLOYMENT
SECTION I - REMARKS
38. THE MOST CURRENT INFORMATION ON VA EDUCATION BENEFITS IS AVAILABLE ONLINE AT www.benefits.va.gov/gibill. 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
PAGE 4
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, JUN 2017
(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
JUN 2017
22-5490
SUPERSEDES VA FORM 22-5490, DEC 2016,
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.
NOTE: The number on the instructions match the item numbers on this application. Items not mentioned are self-explanatory.
ITEM 8. The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct
deposit. Please attach a voided personal check or deposit slip or provide the information requested below to enroll in direct deposit. If you
do not have a bank account, you must receive your payment through Direct Express Debit MasterCard. To request a Direct Express Debit
MasterCard, you must apply at www.usdirectexpress.com
or by telephone at 1-800-333-1795. If you elect not to enroll, you must
contact representatives handling waiver requests for the Department of Treasury at 1-888-224-2950. They will address any questions or
concerns you may have and encourage your participation in EFT.
ITEM 16. 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 17B. 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.benefits.
va.gov/gibill
"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.
ITEMS 17C and 17D. 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 20. 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.
ITEM 21. If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where
you and/or your spouse resided at the time of marriage or where you and/or your spouse resided when you filed your claim (or a later date
when you became eligible for benefits) (38 U.S.C. § 103(3)). Additional guidance on when VA recognizes marriages is available at http://
www.va.gov/opa/marriage/.
INTERNET VERSION AVAILABLE - You may complete and submit this application on-line at www.benefits.va.gov/gibill
. Click on "GI
Bill: Apply for Benefits."
INFORMATION AND INSTRUCTIONS (Continued)
ITEMS 24 and 25. 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 the line of duty by
hostile force, forcibly detained or interned in the line of duty by hostile force, or forcibly detained or interned in the 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 surviving 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.
To qualify for the Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship, you must be the surviving spouse or child of an
individual who died in the line of duty while serving on active duty as a member of the Armed Forces after September 10, 2001.
ITEMS 24 and 25. Irrevocable Election - Your decision to elect one benefit over the other CANNOT be changed once you have
submitted this application.
Child - Your election will be effective as of the date indicated in Item 26 of this form, if you elected to receive education benefits instead of
Dependency and Indemnity Compensation (DIC). If Item 26 is not applicable, your election will be effective on the date shown in Item 39B
or the date VA receives this application, whichever is earlier.
Surviving Spouse - Your election will be effective on the date shown in Item 39B or the date VA receives this application, whichever is
earlier.
ITEM 24A. By selecting this box you are agreeing to the following statement: I understand that if I am also eligible for Fry Scholarship
benefits then I am electing to receive DEA benefits in lieu of any Fry Scholarship benefits for which I am currently eligible including Fry
Scholarship benefits based on the death of the individual listed in Item 10 of this application, as well as, Fry Scholarship benefits based on
the death of any other individuals not identified on this application.
ITEM 24B. By selecting this box you are agreeing to the following statement: I understand that I am electing to receive Fry
Scholarship benefits in lieu of any DEA benefits for which I am currently eligible including DEA benefits based on the death of the
individual listed in Item 10 of this application, based on the death of any other individuals not identified on this application, based on a
spouse who has a total disability permanent in nature resulting from a service-connected disability, or based on any other criteria as listed
in 38 U.S.C. § 3501(a)(1).
IITEM 25A. By selecting this box you are agreeing to the following statement: I understand that if I am also eligible for Fry
Scholarship benefits based on the death of the individual listed in Item 10 of this application then I am electing to receive DEA benefits in
lieu of any Fry Scholarship benefits based on that death. Furthermore, I understand that even after this election I will continue to retain any
current eligibility to Fry Scholarship benefits if the eligibility is based on the death of an individual not listed in Item 10 of this application.
ITEM 25B. By selecting this box you are agreeing to the following statement: I understand that I am electing to receive Fry
Scholarship benefits in lieu of any DEA benefits for which I am currently eligible based on the death of the individual identified in Item 10.
Furthermore, I understand that even after this election I will continue to retain any current eligibility to DEA benefits if the eligibility is based
on the death of an individual not listed in Item 10 of this application, based on a parent who has a total disability permanent in nature
resulting from a service-connected disability, or based on any other criteria as listed in 38 U.S.C. § 3501(a)(1).
ITEM 26. Your election to receive Survivors' and Dependents' Education Assistance (DEA) in lieu of payments of compensation, pension,
and Dependents' Indemnity Compensation (DIC) 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.
VA FORM 22-5490, JUN 2017
VA FORM 22-5490, JUN 2017
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.
benefits.va.gov/gibill.
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 the last page for addresses of the 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
You may complete and submit your application online at www.benefits.va.gov/gibill
or be sure to do the following:
VA
VT
APO/FPO AA
US Virgin
Islands
Foreign
Schools
WV
TN
NJ
ALAK
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 MA
MD NCME NH
PANY RI
AR AZ
UT
OK
CA
HI
FL
ID
LA
TX
ORNV
SERVES THE FOLLOWING STATES
MS
NM
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 32432
St. Louis, MO 63132-0832
CO IL
IA
IN
KS MI
KY
MN
MO NE
MT
ND
OH
SD
SERVES THE FOLLOWING STATES
SC WA
APO/FPO AP
VA FORM 22-5490, JUN 2017
WI WY
Philippines
Guam
GA
PR
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DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS (Under Provisions (Piedmont Community College)

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Completed 3 February 2021

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