Fillable REQUEST FOR CHANGE OF PROGRAM OR PLACE OF (Arizona Western College)

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REQUEST FOR CHANGE OF PROGRAM OR PLACE OF (Arizona Western College)

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1C. APPLICANT'S TELEPHONE NUMBER (Including Area Code)
5. DIRECT DEPOSIT INFORMATION
(Complete this item only if you wish to start direct deposit or your direct deposit information has changed.)
Please attach a voided personal check or provide the information in items A through D below. NOTE: Direct Deposit is not available for the
Post-Vietnam Era Educational Assistance Program (chapter 32) nor for section 903.
A. TYPE OF ACCOUNT
3. HOW WILL YOU TAKE TRAINING?
4C. IF CHANGING SCHOOLS, GIVE NAME AND COMPLETE ADDRESS OF
NEW SCHOOL OR TRAINING ESTABLISHMENT YOU ARE PLANNING
TO ATTEND
(If applicable)
PART I - IDENTIFICATION AND PERSONAL INFORMATION
OMB Control No. 2900-0074
Respondent Burden: 20 minutes
REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
1B. MAILING ADDRESS (Complete street address, City, State, and 9-digit ZIP Code)
VA DATE STAMP
PART III - DIRECT DEPOSIT INFORMATION
4D. NAME AND COMPLETE ADDRESS OF OLD OR CURRENT SCHOOL OR
TRAINING ESTABLISHMENT
4A. WHAT EDUCATION, PROFESSIONAL OR VOCATIONAL GOAL ARE
YOU WORKING TOWARD?
SAVINGS
4B. WHAT IS THE NAME OF THE PROGRAM YOU ARE REQUESTING?
PART II - YOUR PROGRAM INFORMATION
1A. NAME OF APPLICANT (First, Middle, Last)
NATIONAL ADMISSIONS EXAMS OR
NATIONAL EXAMS FOR CREDIT
H.
CHAPTER 33
(Post-9/11 GI BILL)
CHAPTER 30 (Montgomery GI Bill - Active
Duty)
VA FORM
OCT 2010
22-1995
SUPERSEDES VA FORM 22-1995, NOV 2008,
WHICH WILL NOT BE USED.
CHECKING
C. 9 DIGIT ROUTING OR TRANSIT NUMBER D. ACCOUNT NUMBER
LICENSING & CERTIFICATION TEST
TRANSFER OF ENTITLEMENT PROGRAM
B. NAME OF FINANCIAL INSTITUTION
1E. APPLICANT'S E-MAIL ADDRESS
4E. TELL US WHEN AND WHY YOU STOPPED TRAINING AT YOUR PRIOR SCHOOL OR ESTABLISHMENT. CONTINUE IN REMARKS, ITEM 10, OR ON A SEPARATE
SHEET IF NECESSARY.
DO NOT WRITE IN THIS SPACE
1D. VA FILE NUMBER
EVENING
1F. SOCIAL SECURITY OF APPLICANT
(For transferability cases,
enter the veteran's social security number)
DAY
FLIGHT TRAINING
CHAPTER 32
(Veterans Educational Assistance
Program including section 903)
CHAPTER 1606 (Montgomery GI Bill-
Selected Reserve)
B.
A.
F.
TUITION ASSISTANCE TOP-UP
(Active Duty Only)
D.
G.
F.
C.
2. EDUCATION BENEFIT YOU WANT TO RECEIVE
(Only Select One)
E.CORRESPONDENCEB.
SCHOOL ATTENDANCE
APPRENTICESHIP OR ON-THE-JOB TRAININGC.
A. COOPERATIVE TRAININGD.
CHAPTER 1607 (Reserve Educational
Assistance Program)
E.
7. RECENT PERIODS OF SERVICE (PERIODS OF ACTIVE DUTY SINCE YOUR INITIAL PERIOD OF ACTIVE DUTY.) Please complete this section
for each period of your active duty since your initial period of active duty if you have not previously reported this information. It will help VA
process your claim if you attach a certified copy of "Member 4 Copy" of your DD Form 214 for each period of active service.
(Don't report
Active Duty for Training.)
( )
C. IS EITHER YOUR FATHER OR MOTHER DEPENDENT UPON YOU FOR FINANCIAL SUPPORT?
PART IV - MISCELLANEOUS INFORMATION
NOQUESTIONS YES
A. ARE YOU CURRENTLY MARRIED?
( )
6. INFORMATION ON DEPENDENTS (COMPLETE THIS ITEM ONLY IF YOU SERVED BEFORE JANUARY 1, 1977 (or had a delayed entry before
January 2, 1978)
AND YOU CURRENTLY HAVE DEPENDENTS.)
C. WERE YOU
INVOLUNTARILY CALLED TO
ACTIVE DUTY FOR THIS
PERIOD?
(If yes send in
copies of your orders)
B. DO YOU HAVE ANY CHILDREN WHO ARE :
8. DO YOU EXPECT TO RECEIVE EDUCATIONAL BENEFITS UNDER THE GOVERNMENT EMPLOYEE'S TRAINING ACT (GETA) FOR THE SAME COURSE(S) YOU WILL
RECEIVE VA EDUCATION BENEFITS?
(Answer only if you are a Federal Government employee)
A. BRANCH OF SERVICE
AND RESERVE OR GUARD
COMPONENT SERVING IN
DURING ACTIVE DUTY
E. IF THIS ACTIVE DUTY IS
NATIONAL GUARD DUTY, INDICATE IF
AUTHORITY IS TITLE 10 (FEDERAL) OR
TITLE 32 (STATE).
(ATTACH COPIES
OF ANY ORDERS)
B. BEGINNING AND ENDING
DATES OF ACTIVE DUTY
D. WHAT WAS THE CHARACTER
OF YOUR DISCHARGE?
NOTE: DO NOT INCLUDE FULL TIME ASSIGNMENT BY A SERVICE DEPARTMENT TO A CIVILIAN SCHOOL FOR A COURSE OF EDUCATION; ATTENDANCE AT A
SERVICE ACADEMY; OR NON-CREDITABLE TIME (TIME LOST BECAUSE OF INDUSTRIAL OR AGRICULTURAL FURLOUGH, ARREST WITHOUT ACQUITTAL, BEING
AWOL, DESERTION, SENTENCE OF COURT-MARTIAL, ETC.)
9. ARE YOU RECEIVING OR DO YOU ANTICIPATE RECEIVING ANY MONEY (including but not limited to Federal Tuition Assistance) FROM THE ARMED FORCES
OR PUBLIC HEALTH SERVICE FOR THE COURSE FOR WHICH YOU HAVE APPLIED TO VA FOR EDUCATION BENEFITS? IF YOU WILL RECEIVE SUCH BENEFITS,
CHECK "YES." SHOW COMPLETE DETAILS IN THE REMARKS SECTION TO INCLUDE THE SOURCE OF THE FUNDS. NOTE: IF YOU ARE APPLYING FOR
THE TUITION ASSISTANCE TOP-UP BENEFIT, CHECK "NO."
(Answer only if you are on Active Duty)
NOYES
( )
( )
YES NO
10. REMARKS
YES NO
PENALTY - Willful 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 V - CERTIFICATION AND SIGNATURE OF APPLICANT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief. If on active duty, I also certify that I
have consulted with an Education Service Officer (ESO) regarding my education program.
11A. SIGNATURE OF APPLICANT (DO NOT PRINT) 11B. DATE SIGNED
(1) UNDER AGE 18 OR
(2) OVER 18 BUT UNDER AGE 23, NOT MARRIED AND ATTENDING SCHOOL? OR
(3) OF ANY AGE PERMANENTLY HELPLESS FOR MENTAL OR PHYSICAL REASONS?
VA FORM 22-1995, OCT 2010
When Should You Use This Form?
Use this form when:
you're changing schools,
you're changing your educational, professional, vocational goal,
you left your program due to unsatisfactory attendance, progress, or conduct;
and you're now reentering the same program, or
you were receiving VA education benefits as a veteran and now wish to receive
benefits while on active military duty.
INSTRUCTIONS FOR SPECIFIC ITEMS ON THE FORM
Most items on this form are self-explanatory. Here is additional information on certain items.
Item #4A: Here are some examples of what we mean by "goals":
Educational goal: GED certificate, high school diploma, bachelor degree, master degree, Ph.D
Professional goal: lawyer physician, teacher, physical therapist, medical technologist, medical
records librarian
Vocational goal: stenographer, machinist, electronic technician, X-ray technician, radio and
TV service technician, automobile mechanic, practical nurse.
Items #6: Provide your dependents information only if you have military service before
January 1, 1977 (or delayed entry before January 2, 1978).
Items #11A and 11B: Make sure you sign and date these items. If you are currently on active duty,
have your Education Service Officer sign and date Items 12A and 12B.
TO FILE THIS FORM:
(A) If you have selected a school or training establishment,
Step1: Mail the completed form to the VA Regional Processing Office in the region of that school's or
establishment's physical address: Determine the correct office from the list below.
Step 2: Notify 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.
Step 3: Wait for VA to process your application and notify you of our decision concerning your
continued eligibility for education assistance.
(B) If you have not selected a school or training establishment,
Step 1: Mail the completed form to the VA Regional Processing Office in the region of your home
address. Determine the correct office from the list on on the next page.
Step 2: Wait for VA to process your application and notify you of our decision concerning your
continued eligibility for educational assistance.
If You Need Help
If you need help in completing this form, you can contact us through our home page on the Internet.
Our website is: www.gibill.va.gov. Click on Ask a Question and Find Answers. Or you may call us toll
free at 1-888-GI-BILL-1 (1-888-442-4551.) If you're hearing impaired, call 1-800-829-4833. Please call
1-800-827-1000 if you want a VA counselor to help you in planning your program.
INSTRUCTIONS & INFORMATION
VA FORM 22-1995, OCT 2010
PRIVACY ACT NOTICE: 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, section 1.526 for
routine uses (e.g. VA sends 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 the VA to
obtain further information as may be necessary from the school for the VA to properly process the veteran's
education claim or to monitor his or her progress during training) as identified in the VA system of records,
58VA21/22, Compensation, Pension, Education and Rehabilitation Records - VA, and published in the Federal
Register. Your obligation to respond is required to obtain or retain education benefits. The requested information
is considered relevant and necessary to determine the maximum benefits under the law. While you do not have to
respond, VA cannot process your claim for education assistance unless the information is furnished as required by
existing law (38 U.S.C. 3471). 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.
Southern Region:
VA Regional Office
P.O. Box 100022
Decatur, GA 30031-7022
RESPONDENT BURDEN: We need this information to determine your continued eligibility to VA education
benefits (38 U.S.C. 3471). Title 38, United States Code, allows us to ask for this information. We estimate that you
will need an average of 20 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.
Serves the following states
SC
GA
US Virgin Islands
NC
Eastern Region:
VA Regional Office
P.O. Box 4616
Buffalo, NY 14240-4616
Serves the following states
VT
Foreign Schools
MD
NY
CT ME
NJ
RI
VA
DE
MA
OH
WV
DC
NH
PA
Central Region:
VA Regional Office
P.O. Box 66830
St. Louis, MO 63166-6830
Serves the following states
KS
MO
CO IN
MN
ND
IA
KY
MT
IL
MI
NE
Western Region:
VA Regional Office
P.O. Box 8888
Muskogee, OK 74402-8888
Serves the following states
OR
CA
MS
AK AZ
LA
OK
Philippines
AL
HI
NM
TX
AR
ID
NV
SD
WYTN WI
VA FORM 22-1995, OCT 2010
FL PR
WA
UT
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REQUEST FOR CHANGE OF PROGRAM OR PLACE OF (Arizona Western College)

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