Fillable Form 22 5490 (Vance-Granville Community College)

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Form 22 5490 (Vance-Granville Community College)

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DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(Under Provisions of chapters 33 and 35, of title 38, U.S.C.)
9. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
Request to Opt-Out of Information Sharing With Educational Institutions
ACCOUNT NUMBER
22-5490
VA FORM
OCT 2018
6. TELEPHONE NUMBER(S)
(Including Area Code)
OMB Approved No. 2900-0098
Respondent Burden: 45 minutes
Expiration Date: 10/31/2021
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?
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
14A. DID PARENT OR SPOUSE DIE WHILE SERVING ON ACTIVE DUTY?
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, JUN 2017,
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
PAGE 1
By checking the box, I CERTIFY THAT THE DEPARTMENT OF VETERANS AFFAIRS (VA) does not have my permission to share information about my veterans'
education benefits with any educational institution. I understand that sharing my information with my school is intended to support the certification process and that
"opting-out" may delay that process. See Information and Instructions on Page 7 for more information.
PART I - APPLICANT INFORMATION
PART II - QUALIFYING INDIVIDUAL INFORMATION
PART III - RELATIONSHIP AND BENEFIT INFORMATION
(If "No," is checked then you do not qualify
for the Fry Scholarship)
14B. DATE OF DEATH
(If "Yes," is checked complete
Item 14B)
14C. DATE LISTED AS MISSING IN ACTION
OR P.O.W.
YES
NO
17. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL (Check only one)
SPOUSE/SURVIVING SPOUSE
(Please complete only Section I on page 2, and then proceed to Part V)
CHILD/STEPCHILD/ADOPTED CHILD
(Please complete only Section II on page 2, and then proceed to Part V)
SECTION I - SPOUSE/SURVIVING SPOUSE
18. IS A DIVORCE OR ANNULMENT PENDING TO THE
QUALIFYING INDIVIDUAL?
19. IF YOU ARE THE SURVIVING SPOUSE, HAVE YOU REMARRIED?
YES
NO
(If "Yes," please provide date of remarriage)
YES
NO
IMPORTANT ►
SECTION I - SPOUSE/SURVIVING SPOUSE (Continued)
SOCIAL SECURITY NUMBER OF APPLICANT
22. 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 OR PENSION BENEFITS (Please read Information and Instructions Page 6 for additional information)
PAGE 2
VA FORM 22-5490, OCT 2018
IMPORTANT: If you are over the age of 18 once you receive either the DEA or FRY SCHOLARSHIP benefits, you will no longer receive payments of Dependency
and Indemnity Compensation (DIC) or Pension and you may no longer be claimed as a dependent in a Compensation claim. If you are under the age of 18, on your 18th
birthday you will lose eligibility for DIC or Pension payments and you will no longer be claimed as a dependent in a Compensation claim.
CAREFULLY READ THE INFORMATION AND INSTRUCTIONS ON PAGE 6, ITEM 22 BEFORE COMPLETING THE ELECTION BOX BELOW.
YOU ARE STRONGLY ENCOURAGED TO DISCUSS YOUR ELECTION WITH A VA COUNSELOR.
YES
NO
20. SPOUSE/SURVIVING SPOUSE SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW:
PLEASE CAREFULLY READ THE INFORMATION AND INSTRUCTIONS ON PAGE 5, ITEM 20 BEFORE SELECTING BOX "A"
OR "B" BELOW REGARDING THE BENEFIT YOU ARE APPLYING FOR. THE INFORMATION AND INSTRUCTIONS ON PAGE 5
ALSO PROVIDE LINKS TO VA WEBSITES WHERE YOU WILL BE ABLE TO COMPARE "DEA" AND "FRY" BENEFITS. YOU
WILL ALSO FIND OTHER ELIGIBILTIY RELATED INFORMATION THERE.
A.
AS A SPOUSE OR SURVIVING SPOUSE BASED ON 100%
PERMANENT AND TOTAL DISABILITY, SERVICE CONNECTED
OR LINE OF DUTY DEATH, I AM APPLYING FOR
CHAPTER 35 - DEA BENEFITS.
B.
AS A SURVIVING SPOUSE BASED ON LINE OF DUTY
DEATH AFTER SEPTEMBER 10, 2001, I AM APPLYING
FOR CHAPTER 33 - FRY SCHOLARSHIP BENEFITS.
NOTE - BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.
NOTE - BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.
SECTION II - CHILD/STEPCHILD/ADOPTED CHILD
21. CHILD/STEPCHILD/ADOPTED CHILD SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW:
IMPORTANT ►
PLEASE CAREFULLY READ THE INFORMATION AND INSTRUCTIONS ON PAGE 6, ITEM 21 BEFORE SELECTING BOX "A"
OR "B" BELOW REGARDING THE BENEFIT YOU ARE APPLYING FOR. THE INFORMATION AND INSTRUCTIONS ON PAGE 5
ALSO PROVIDE LINKS TO VA WEBSITES WHERE YOU WILL BE ABLE TO COMPARE "DEA" AND "FRY" BENEFITS. YOU
WILL ALSO FIND OTHER ELIGIBILTIY RELATED INFORMATION THERE.
A.
I AM APPLYING FOR CHAPTER 35 - DEA BENEFITS.
NOTE - BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.
Important - If your parent died in the line of duty prior to August 1, 2011, you
may apply for both DEA and Fry Scholarship benefits.
If you are eligible for both Chapter 35 (DEA) and Chapter 33 (Fry Scholarship) benefits
and you would like to use the Chapter 35 benefit first, check the box below.
CHAPTER 35 - DEA
B.
I AM APPLYING FOR CHAPTER 33 - FRY SCHOLARSHIP
BENEFITS.
NOTE - BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.
Important - If your parent died in the line of duty prior to August 1, 2011, you
may apply for both DEA and Fry Scholarship benefits.
If you are eligible for both Chapter 35 (DEA) and Chapter 33 (Fry Scholarship)
benefits and you would like to use the Chapter 33 benefit first, check the box below.
CHAPTER 33 - FRY SCHOLARSHIP
PART IV - BENEFIT AND TYPE OF EDUCATION OR TRAINING INFORMATION
23A. DATE YOU WILL BEGIN SCHOOL OR TRAINING (MM/DD/YYYY)
23B. TYPE OF EDUCATION OR TRAINING (Check ONE box)
COLLEGE OR OTHER SCHOOL
FARM COOPERATIVE
23C. [ DEA ONLY] DO YOU HAVE A MENTAL OR PHYSICAL DISABILITY FOR
WHICH YOU ARE SEEKING SPECIAL RESTORATIVE TRAINING?
(See Information and Instructions, Page 6, for details regarding restorative training)
23D. [ DEA ONLY] DO YOU HAVE A MENTAL OR PHYSICAL
DISABILITY FOR WHICH YOU ARE SEEKING SPECIAL
VOCATIONAL TRAINING? (See Information and Instructions,
Page 6, for details regarding special vocational training)
YES
NO
YES
NO
LICENSING OR CERTIFICATION TEST
APPRENTICESHIP OR OTHER ON-THE-JOB TRAINING
NATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDIT
CORRESPONDENCE COURSE
FLIGHT TRAINING (Fry Scholarship only)
FROM
34C. DATES OF TRAINING
34B. NAME AND LOCATION
OF SCHOOL
(City and State)
34D. NUMBER OF
SEMESTER, QUARTER, OR
CLOCK HOURS COMPLETED
PART V - APPLICATION HISTORY
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 the box for Item 27E above.
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)
31. INFORMATION ABOUT YOUR PERIOD(S) OF ACTIVE DUTY (If you need additional space use Item 37, Remarks)
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, OCT 2018
33. DATE
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
34E. DEGREE, DIPLOMA
OR CERTIFICATE
RECEIVED
OTHER
(Specify)
DISCONTINUED HIGH SCHOOL
34F. MAJOR FIELD OR
COURSE OF STUDY
34A. TYPE
OF SCHOOL
HIGH SCHOOL
COLLEGE
VOCATIONAL
OR TRADE
SECTION I - EDUCATION & TRAINING
24. NAME AND ADDRESS OF SCHOOL OR TRAINING FACILITY (Number and street or rural route, city or P.O., State and ZIP Code)
25. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE, IF KNOWN (e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer)
26. WOULD YOU LIKE TO RECEIVE VOCATIONAL AND EDUCATIONAL COUNSELING?
(See Information and Instructions, Item 26 for more information regarding
vocational and educational counseling)
YES
NO
PART VI - APPLICANT'S MILITARY SERVICE INFORMATION
(NOTE: Chapter 35 benefits are not payable while an eligible person is on active duty)
PART VII - EDUCATION, TRAINING AND EMPLOYMENT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.
SECTION III - VA EDUCATION BENEFITS PAMPHLET
SECTION II - REMINDERS
SECTION I - REMARKS
35. CURRENT AND PAST EMPLOYMENT
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)
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
SECTION II - EMPLOYMENT
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 Items 36A and 36B only if you are a civilian employee of the U.S. Government.
A. EMPLOYER
B. JOB TITLE
C. NUMBER OF MONTHS
EMPLOYED
39A. SIGNATURE OF APPLICANT (DO NOT PRINT)
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, OCT 2018
PART VII - EDUCATION, TRAINING AND EMPLOYMENT (Continued)
PART VIII - REMARKS, REMINDERS AND VA EDUCATION BENEFITS PAMPHLET
PART IX - CERTIFICATION AND SIGNATURE OF APPLICANT
PART X - SIGNATURE OF PARENT, GUARDIAN OR CUSTODIAN
(This section must be completed by the parent, guardian, or custodian if the applicant is a minor)
40. NAME OF PARENT, GUARDIAN, OR CUSTODIAN (First, Middle Initial, Last) (Type or print)
41. MAILING ADDRESS OF PARENT, GUARDIAN, OR CUSTODIAN
City, State, ZIP Code
Apt./Unit Number
Number and Street
Primary:
Secondary:
42A. TELEPHONE NUMBER(S) OF PARENT, GUARDIAN, OR CUSTODIAN (Include Area Code)
42B. E-MAIL ADDRESS OF PARENT, GUARDIAN, OR CUSTODIAN (If applicable)
43A. SIGNATURE OF: (Check one)
SIGN HERE ►
IN INK
(DO NOT PRINT)
PARENT
GUARDIAN
CUSTODIAN
43B. DATE SIGNED
ITEM 8. The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit.
To enroll in direct deposit, please attach a voided personal check, deposit slip, or provide the information requested in Item 8. If you do not have a bank
account, please visit https://www.benefits.va.gov/benefits/banking.asp. This website provides information about the Veterans Benefits Banking
Program (VBBP), and a link to banks and credit unions that may fit your needs. You may also call 1-800-827-1000. If you elect not to enroll, you must
contact representatives handling waiver requests for the Department of the the Treasury at 1-888-224-2950. They will encourage your participation in
EFT and address any questions or concerns you may have.
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 17. 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/.
ITEM 20. IMPORTANT - PLEASE READ THE INFORMATION BELOW BEFORE MAKING YOUR SELECTION IN ITEM 20A OR 20B REGARDING
THE BENEFIT YOU ARE APPLYING FOR.
• To qualify for the Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship, you must be the surviving spouse 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.
• To qualify for Survivor's and Dependents' Educational Assistance (DEA) you must be either:
(1) The spouse of a veteran who is permanently and totally disabled as a result of a service-connected disability, OR
(2) The spouse 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
a foreign government or power for more than 90 days, OR
(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, OR
(4) The surviving spouse 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 service person is likely to be discharged or released from such service for such disability.
NOTE: If you are eligible for both Chapter 35 Survivors' and Dependents' Educational Assistance Program (DEA) and Chapter 33 Post-9/11 GI Bill
Marine Gunnery Sergeant John David Fry Scholarship (Fry Scholarship) benefits, you must relinquish/give up entitlement to one or the other benefit for
which you are eligible, even if entitlement arises from separate events. In other words, you must forfeit eligibility to the other benefit even if your
eligibility is due to:
• A separate Period of Service (POS) other than the one for which the death of the spouse is associated; OR
• A separate POS other than the one for which your spouse has a total disability permanent in nature resulting
from a service-connected disability; OR
• A separate POS based on any other criteria as listed in 38 U.S.C. § 3501(a)(1); OR
• Death of any other individual identified in Item 10 of this application.
IMPORTANT: You cannot retain eligibility for both programs simultaneously. Therefore, by checking either box "A" or box "B" in Item 20, you agree and
understand that you are making an irrevocable election to receive the selected benefit and your election may not be changed.
IMPORTANT: 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.
Note: Before making your election selection, you can compare the differences between (DEA) and (FRY), and the benefits each provide in order
to help you make the best choice that suits your needs.This benefit comparison information can be found on the VA website at:
https://www.benefits.va.gov/gibill/docs/factsheets/fry_scholarship.pdf. You can also find additional information about each program by visiting the
GI Bill website at: https://benefits.va.gov/gibill/ and using the comparison tool.
(Please retain these Information and Instructions Pages for future reference)
INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(VA FORM 22-5490)
VA FORM 22-5490, OCT 2018
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. VA forms are
available at www.va.gov/vaforms.
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."
PAGE 5
NOTE: The numbers on these Information and Instructions pages match the item numbers on this application. Items not mentioned are
self-explanatory.
INFORMATION AND INSTRUCTIONS (Continued)
ITEM 21. IMPORTANT - PLEASE READ THE INFORMATION BELOW BEFORE MAKING YOUR SELECTION IN ITEM 21A OR 21B REGARDING
THE BENEFIT YOU ARE APPLYING FOR.
• To qualify for the Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship, you must be the dependent 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.
• To qualify for Survivor's and Dependents' Educational Assistance (DEA) you must be either:
(1) The child of a veteran who is permanently and totally disabled as a result of a service-connected disability; OR
(2) The 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 a foreign
government or power for more than 90 days, OR
(3) The 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, OR
(4) The 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 service person is likely to be discharged or released from such service for such disability.
PARENT'S DEATH PRIOR TO AUGUST 1, 2011 -
• The election you choose in Item 21 does not eliminate your eligibility for the alternate education benefit (either
Survivor's and Dependents' Educational Assistance (DEA) and the Chapter 33 Post-9/11 GI Bill Marine Gunnery
Sergeant John David Fry Scholarship (Fry Scholarship)) based on the same event (i.e., your parent's line of duty death
that occurred prior to August 1, 2011).
PARENT'S DEATH ON OR AFTER AUGUST 1, 2011 -
• The election you choose in Item 21 does eliminate your eligibility for the alternate education benefit (either Survivors' and Dependents'
Educational Assistance Program (DEA) and the Chapter 33 Post-9/11 GI Bill Marine Sergeant John David Fry Scholarship (Fry Scholarship)),
based on the same event (i.e., your parent's line of duty death that occurred on or after August 1, 2011). Therefore, you must relinquish/give up
eligibility entitlement to the benefit that you are not applying for but only with regard to the entitlement arising from the same event
(i.e., your parent's line of duty death that occurred on or after August 1, 2011). By checking either box "A" or box "B" in Item 21, you agree and
understand that you are making an irrevocable election to receive the selected benefit and your election may not be changed.
IMPORTANT: Unlike spouses, children may be able to retain eligibility for both programs simultaneously if they qualify under different events and
individuals (i.e., a separate parent's line of duty death that occurred on or after August 1, 2011).
IMPORTANT: 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.
NOTE: Before making your election selection, you can compare the differences between (DEA) and (FRY), and the benefits each provide in order to
help you make the best choice that suits your needs. This benefit comparison information can be found on the VA website at:
https://www.benefits.va.gov/gibill/docs/factsheets/fry_scholarship.pdf. You can also find additional information about each program by visiting the GI Bill
website at https://benefits.va.gov/gibill/, and using the comparison tool.
ITEM 22. Your election to receive Survivors' and Dependents' Education Assistance (DEA) or Chapter 33 Post-9/11 GI Bill Marine Gunnery Sergeant
John David Fry Scholarship (Fry Scholarship) in lieu of payments of compensation, pension, and Dependents' Indemnity Compensation (DIC) is final
and cannot be changed. This means that if you are 18 years old, payments of compensation, pension, and Dependents' Indemnity Compensation (DIC)
will be terminated upon issuance of a DEA or Fry Scholarship benefit payment. If you are under the age of 18, these benefits will be terminated on your
18th birthday. If you are planning to pursue a program of education for more than 36 months, you should consider deferring receipt of DEA or Fry
Scholarship benefits. We strongly recommend that you discuss your education or training plans with a VA counselor before making a decision.
ITEM 23B. 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 Exams or National Exams for Credit" - You may be reimbursed for the cost of approved tests for admission to or credit at
institutions of higher learning.
"Correspondence Course" - You 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, you can go to the VA website
at: https://www.benefits.va.gov/gibill/correspondence_training.asp.
"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 23C AND 23D - 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 - 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.
VA FORM 22-5490, OCT 2018
PAGE 6
Students and School Certifying Officials calling from outside the United States can contact VA by phone at:
001-918-781-5678 during business hours, 7 a.m. - 6 p.m. CST, Monday - Friday. This is not a toll-free number but the
caller will be routed to the next available customer service representative. Non-overseas customers should call the toll-
free number shown in "Additional Help Completing Application".
VA FORM 22-5490, OCT 2018
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 the 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 page 8
for addresses of the VA Regional Processing 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 page 8 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:
PAGE 7
CONTACT VA FROM OVERSEAS
REQUEST TO OPT-OUT OF INFORMATION SHARING WITH EDUCATIONAL INSTITUTIONS
The Harry W. Colmery Veterans Educational Assistance Act of 2017 (Public Law 115-48), also known as the "Forever
GI Bill," requires the Department of Veterans Affairs (VA) to make available to educational institutions information about
the amount of educational assistance to which a veteran or other individual is entitled. However, you may elect to
"opt-out" of these disclosures and have VA withhold this information instead.
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, OCT 2018
WI WY
Philippines
Guam
GA
PR
PAGE 8
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Form 22 5490 (Vance-Granville Community College)

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Completed 25 July 2020

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