Fillable REQUEST FOR CHANGE OF PROGRAM OR PLACE OF (Gadsden State Community College)

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REQUEST FOR CHANGE OF PROGRAM OR PLACE OF (Gadsden State Community College)

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1C. APPLICANT'S TELEPHONE NUMBER (Including Area Code)
3. HOW WILL YOU TAKE TRAINING?
4C. IF CHANGING SCHOOLS, PROVIDE 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
Expiration Date: 10/31/2021
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
DO NOT WRITE IN THIS SPACE
4D. PROVIDE NAME AND COMPLETE ADDRESS OF PREVIOUS SCHOOL OR
TRAINING ESTABLISHMENT
(If only changing schools, list current school.)
4A. WHAT EDUCATIONAL, PROFESSIONAL OR VOCATIONAL GOAL ARE
YOU WORKING TOWARD?
4B. WHAT IS THE NAME OF THE PROGRAM YOU ARE REQUESTING?
PART II - YOUR PROGRAM INFORMATION
1A. NAME OF APPLICANT (Last, First, Middle)
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 2018
22-1995
SUPERSEDES VA FORM 22-1995, DEC 2016,
WHICH WILL NOT BE USED.
LICENSING & CERTIFICATION TEST
TRANSFER OF ENTITLEMENT PROGRAM
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. (If applicable)
1D. VA FILE NUMBER
EVENING
1F. SOCIAL SECURITY OF APPLICANT
(For transferability cases,
enter the veteran's social security number)
DAY
FLIGHT TRAINING
EDITH NOURSE ROGERS STEM
SCHOLARSHIP
CHAPTER 1606
(Montgomery GI Bill-
Selected Reserve)
B.
A.
F.
TUITION ASSISTANCE TOP-UP
(Active Duty Only)
E.
G.
G.
C.
2. EDUCATION BENEFIT YOU WANT TO RECEIVE
(Only Select One)
E.CORRESPONDENCEB.
SCHOOL ATTENDANCE
APPRENTICESHIP OR ON-THE-JOB
TRAINING
C.
A. COOPERATIVE TRAININGD.
CHAPTER 1607 (Reserve Educational
Assistance Program)
F.
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 3 for more information.
Request to Opt-Out of Information Sharing With Educational Institutions
CHAPTER 32 (Veterans Educational Assistance
Program including section 903)
D.
STEM SCHOLARSHIP APPLICANTS ONLY
4F. ARE YOU ENROLLED IN AN UNDERGRADUATE STEM DEGREE PROGRAM OR HAVE YOU GRADUATED FROM A STEM DEGREE PROGRAM AND PURSUING
A TEACHING CERTIFICATION?
YES NO
4G. ARE YOU CURRENTLY ON ACTIVE DUTY OR DO YOU ANTICIPATE YOU WILL BE GOING ON ACTIVE DUTY?
YES NO
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.)
6C. IS EITHER YOUR FATHER OR MOTHER DEPENDENT UPON YOU FOR FINANCIAL SUPPORT?
PART IV - MISCELLANEOUS INFORMATION
NOQUESTIONS YES
6A. 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.)
6B. 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)
7A. BRANCH OF SERVICE
AND RESERVE OR GUARD
COMPONENT SERVED IN
DURING ACTIVE DUTY
7E. IF THIS ACTIVE DUTY IS
NATIONAL GUARD DUTY, INDICATE
IF AUTHORITY IS TITLE 10
(FEDERAL) OR TITLE 32 (STATE).
(ATTACH COPIES
OF ANY ORDERS)
7B. BEGINNING AND ENDING
DATES OF ACTIVE DUTY
7C. WERE YOU
INVOLUNTARILY CALLED TO
ACTIVE DUTY FOR THIS
PERIOD? (If yes send in
copies of your orders)
7D. 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)
NO
YES
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 2018
Page 2
5. DIRECT DEPOSIT (Complete this item only if you wish to start, change or stop direct deposit.)
NOTE: To prevent possible delays in payment, claimants are highly encouraged to use Direct Deposit and set up an Electronic Fund Transfer (EFT.) Direct Deposit is
not available for the Post-Vietnam Era Educational Assistance Program (VEAP - Chapter 32) nor for Section 903.
5A. TYPE OF ACCOUNT
PART III - DIRECT DEPOSIT INFORMATION
SAVINGSCHECKING
5C. 9 DIGIT ROUTING OR TRANSIT NUMBER 5D. ACCOUNT NUMBER5B. NAME OF FINANCIAL INSTITUTION
STOP EFT
START OR CHANGE EFT (Please attach a voided personal check or provide the information in items A through D below.)
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,
• you were receiving VA education benefits as a veteran and now wish to receive benefits while on active military duty, or
• you have exhausted your Post-9/11 GI Bill benefits or will exhaust all benefits within the next 180 days and would like to apply for the Edith
Nourse Rogers STEM Scholarship.
INSTRUCTIONS FOR SPECIFIC ITEMS ON THE FORM
Most items on this form are self-explanatory. Here is additional information on certain items.
Item #2: For the Edith Nourse Rogers STEM Scholarship, make sure you check box C “Edith Nourse Rogers STEM Scholarship” and mail to:
Eastern Region VA Regional Office, P.O. Box 4616, Buffalo NY 14240-4616.
Item #4A: Here are some examples of what we mean by "goals":
• Educational goal: GED certificate, high school diploma, bachelor's degree, master's degree, Ph.D
• Professional goal: lawyer, physician, teacher, physical therapist, medical technologist, medical records librarian, stenographer, machinist,
electronic technician, X-ray technician, radio and
• Vocational goal: TV service technician, automobile mechanic, practical nurse.
Item #5: The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called
direct deposit (Direct Deposit is not available for Chapter 32 recipients.) 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 #6: Provide your dependents' information only if you have military service before January 1, 1977 (or delayed entry before
January 2, 1978).
Item #6A: IMPORTANT: 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 become eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on when VA recognizes marriages is available at
http://www.va.
gov/opa/marriage/
.
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 11A and 11B.
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 on page 4. For Edith Nourse Rogers STEM Scholarship recipients, you must mail
your completed form to the Buffalo, NY office listed on page 4.
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 educational
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 page 4.
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.benefits.va.gov/gibill
. Click on the "Contact Us" tab and then the "Ask a Question" tab. Or you may call us toll free at 1-888-GI-BILL-1
(1-888-442-4551.) If you use the Telecommunications Device for the Deaf (TDD), the Federal Relay number is 711. 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 2018
Page 3
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.
Eastern Region:
VA Regional Office
P.O. Box 4616
Buffalo, NY 14240-4616
Serves the following states
CT
DE
DC MA
MD
ME NC
NH
NJ NY PA RI
VA
VT US Virgin Islands Foreign Schools
APO/FPO AA
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, 58VA21/22/28, 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 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.
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.
Central Region:
VA Regional Office
P.O. Box 32432
St. Louis, MO 63132-0832
Serves the following states
CO IA IL IN
KS KY MI MN
MO MT NE ND
OH SD TN WV
WI
WY
Western Region:
VA Regional Office
P.O. Box 8888
Muskogee, OK 74402-8888
Serves the following states
AK AL AR AZ
CA FL GA HI
ID LA MS NM
NV
OK
OR PR
SC TX
UT
WA
Guam Philippines
APO/FPO AP
VA FORM 22-1995, OCT 2018
Page 4
Note: All forms for checkbox C (Edith Nourse Rogers STEM Scholarship) must be sent
to this office.
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REQUEST FOR CHANGE OF PROGRAM OR PLACE OF (Gadsden State Community College)

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