28-8832
EDUCATIONAL/VOCATIONAL COUNSELING APPLICATION
VA FORM
DEC 2008
3B. APPLICANT'S TELEPHONE NUMBER (Including Area Code)
OMB Approved No. 2900-0265
Respondent Burden: 30 minutes
11. IF YOU ARE THE SPOUSE OF A DISABLED VETERAN, IS A DIVORCE OR ANNULMENT PENDING?
2A. SEX OF APPLICANT
1A. NAME OF APPLICANT
(FIRST-MIDDLE-LAST)
7. DATE OF BIRTH
PART I - APPLICANT INFORMATION
2C. DATE OF BIRTH
3A. RELATIONSHIP OF APPLICANT TO VETERAN
3C. MAILING ADDRESS OF APPLICANT
(Number and street or rural route, city or P.O., State and ZIP Code)
12A. IF YOU ARE THE SURVIVING SPOUSE OF A DECEASED VETERAN, HAVE YOU
REMARRIED SINCE HIS OR HER DEATH ?
5. HAVE YOU RECEIVED AN INFORMATION PAMPHLET
EXPLAINING SURVIVORS' AND DEPENDENTS'
EDUCATIONAL ASSISTANCE BENEFITS?
YES
NO
1B. SOCIAL SECURITY NUMBER OF APPLICANT
10. DATE OF DEATH OR DATE LISTED
AS MISSING IN ACTION OR P.O.W.
PART II - INFORMATION CONCERNING DISABLED OR DECEASED VETERAN OR INDIVIDUAL ON ACTIVE DUTY
PART III - SPECIAL INFORMATION CONCERNING APPLICANT
VA DATE STAMP
(For VA Use Only)
8. BRANCH OF SERVICE
SELF
SURVIVING SPOUSE
OTHER PHONE NUMBER
YES
NO
9. SERVICE NUMBER
SUPERSEDES VA FORM 28-8832, JAN 2007,
WHICH WILL NOT BE USED.
FEMALE
PRIVACY ACT INFORMATION: 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 1.576 for routine uses 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. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1).
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 in effect
prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. 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.
RESPONDENT BURDEN: We need this information to determine if the veteran and other beneficiaries are eligible for counseling services that VR&E services
proivde. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 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
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.
6A. NAME OF VETERAN OR INDIVIDUAL ON ACTIVE DUTY ON WHOSE ACCOUNT BENEFITS ARE CLAIMED (FIRST- MIDDLE -LAST)
MALE
6C. VA FILE NUMBER
(If known)
2B. APPLICANT'S E-MAIL ADDRESS
ADOPTED CHILDSTEPCHILD
CHILD
YES
NO
13. HAVE YOU EVER APPLIED FOR ANY OF THE FOLLOWING VA BENEFITS? (Check applicable box(es))
12B. SURVIVING SPOUSE'S AGE AT TIME OF REMARRIAGE
C. DEPENDENTS' EDUCATIONAL ASSISTANCE
(Chapter 35)
B. VETERANS' EDUCATION ASSISTANCE BASED ON YOUR OWN SERVICE (Specify benefit)
A. VOCATIONAL REHABILITATION BENEFITS (Chapter 31)
D. SURVIVORS' AND DEPENDENTS EDUCATIONAL ASSISTANCE (Complete Items 14A and 14B) on reverse)
F. NONE
INTERNET VERSION AVAILABLE -You may download this application form at www.va.gov/vaforms
PRIMARY PHONE NUMBER (Where a message
can be left)
1C. VA FILE NUMBER (If known)
E. OTHER (Specify)
SPOUSE
6B. SOCIAL SECURITY NUMBER
4B. ARE YOU A CHILD, SPOUSE, OR
SURVIVING SPOUSE WITH A DISABILITY
SEEKING SPECIAL VOCATIONAL TRAINING?
YES
NO
4A. ARE YOU A CHILD, 14 YEARS OR OLDER,
SPOUSE, OR SURVIVING SPOUSE WITH A
DISABILITY SEEKING SPECIAL RESTORATIVE
TRAINING?
YES
NO
