Part A - To be completed by the payee (the person who expects to receive benefits for the student).
Read the reverse side of this form before answering the questions below; give full information; typewrite or print in ink.
1. Student's name (first, middle, last) 2. Student's date of birth (mm/dd/yyyy) 3. Student's Social Security Number
4. Is the student married?
Yes
No
If "Yes," show the date at right, sign item 7 of this part, and
return this form. (It is not necessary to complete the rest of the
form.)
Date of marriage (mm/dd/yyyy)
Current
Status
5. Is the student enrolled in
school on a full-time basis
at the present time?
Yes
No
If "No," show the date the student last attended
school on a full-time basis.
Last attended school (mm/dd/yyyy)
Future
Plans
6. After the end of the school
year, does the student
intend to continue as a
full-time student with less
than a 5-month break
between school years?
Yes
No
Undecided
If "Yes," give the details in items 6a and 6b.
If "No" or "Undecided," go to item 7.
}
6a. Enter the date (or approximate
date) the next school year or
term begins after current
enrollment (month, day, year).
6b. Complete name and mailing address (including ZIP code) of the educational institution the
student will attend next year.
Payee
Signs
Here
7. I certify that all information given in this certification is true and correct to the best of my knowledge and belief. I understand that
I must immediately notify the Office of Personnel Management (OPM) if the student transfers to another school, discontinues
school attendance, reduces attendance to less than full-time, marries, or dies. I further agree to return all overpayments of
student benefits, including overpayments that may be erroneously made after I notify OPM of any terminating event. I authorize the
appropriate school official to verify the student's school attendance status to OPM in the manner requested by that agency.
Signature of payee
Email address Daytime telephone number
( )
Date (mm/dd/yyyy)
Part B - To be completed by an official of the educational institution for the school year to .
(month, year) (month, year)
6. Show the total school hours per week:
4. Check the type of educational institution:
College or
university
Vocational institute
Junior college/
community college
1. Is/was the student enrolled in and attending a
full-time course of resident study or training
(not correspondence) for the period requested?
3. Official ending date of the
school year (mm/dd/yyyy)
2. Actual date the student started school for the
school year indicated above (mm/dd/yyyy)
Yes No
High school
Trade school
Technical institute
Other (specify)
5. Show the complete name and mailing address
(including ZIP code) of the educational institution.
a. If college or equivalent, show credit hours
b. If high school or equivalent, show actual clock hours
c. If in a work-study program sponsored by the school,
show hours at work
hours at school
Complete items 7 and 8 below if your institution is not a state college, state university, or public high school.
7. Show the complete name and address (including ZIP code) of the
organization which accredits, licenses, or otherwise recognizes the school.
8. If the educational institution is licensed, show:
a. Current license number: b. Expiration date of current license
(mm/dd/yyyy)
School
Official
Signs
Here
I certify that the information given in regard to requested school enrollment of the
above-named student is true and correct to the best of my knowledge and belief.
Signature of principal, administrator, registrar, etc. Telephone number
Warning: Any intentionally false statement, willful
concealment of material fact, or use of a writing or
document knowing the same to contain a false,
fictitious, or fraudulent statement or entry, is a violation
of the law punishable by a fine of not more than $10,000
or imprisonment of not more than 5 years, or both. (18
U.S.C. 1001)
Title Date (mm/dd/yyyy)
( )
Reverse of RI 25-41
Revised February 2013
