Fillable VA DATE STAMP PART I - APPLICANT INFORMATION (Norco College)

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VA DATE STAMP PART I - APPLICANT INFORMATION (Norco College)

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OMB Approved No. 2900-0099
Respondent Burden: 15 Minutes
Expiration Date: 02/28-2023
DEPENDENTS' REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
(Under Provisions of Chapters 33 and 35, Title 38, U.S.C.)
INTERNET VERSION AVAILABLE - You may complete and submit your application online at www.benefits.va.gov/gibill.
Request to Opt-Out of Information Sharing With Educational Institutions
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 4 for more information.
PART I - APPLICANT INFORMATION
1. NAME (First, Middle Initial, Last)
VA DATE STAMP
(For VA Use Only)
2. SOCIAL SECURITY NUMBER 3. VA FILE NUMBER
4. SEX OF APPLICANT
MALE FEMALE
5. DATE OF BIRTH
6. CURRENT MAILING ADDRESS
(Number and street or rural route, city or P.O., State and 9 DIGIT ZIP Code)
7. TELEPHONE NUMBER(S) (Include Area Code)
A. PRIMARY B. SECONDARY
8. EMAIL ADDRESS
(If applicable)
9. DIRECT DEPOSIT (Complete this item only if you wish to start, change or stop direct deposit) (See Instructions, page 3, Item 9 for more information on Direct Deposit)
NOTE - To prevent possible delays in payment, claimants are encouraged to use Direct Deposit and set up a Electronic Funds Transfer (EFT).
START OR CHANGE DIRECT DEPOSIT (Attach a voided personal check or provide the information
requested in Items A thru D below)
STOP EFT
A. TYPE OF ACCOUNT
CHECKING SAVINGS
B. NAME OF FINANCIAL INSTITUTION C. 9 DIGIT ROUTING OR TRANSIT NUMBER D. ACCOUNT NUMBER
10. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
A. NAME B. ADDRESS C. TELEPHONE NUMBER
PART II - QUALIFYING INDIVIDUAL INFORMATION
11. NAME OF INDIVIDUAL ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (First, Middle, Last)
12. SOCIAL SECURITY NUMBER OR VA FILE NUMBER 13. BRANCH OF SERVICE
14. DATE OF BIRTH 15. DATE OF DEATH OR DATE LISTED AS MIA OR POW 16. IS QUALIFYING INDIVIDUAL CURRENTLY ON ACTIVE DUTY
YES NO
17. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL
SPOUSE SURVIVING SPOUSE CHILD STEPCHILD ADOPTED CHILD
18. DO YOU OR THE QUALIFYING INDIVIDUAL ON WHOSE ACCOUNT YOU ARE CLAIMING BENEFITS HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
YES NO
PART III - APPLICANT'S MILITARY SERVICE INFORMATION
(NOTE: Chapter 35 benefits are not payable while an eligible person is on active duty)
19. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES? (If "No," skip to Part IV)
YES NO
20. INFORMATION ABOUT YOUR PERIODS OF ACTIVE DUTY
A. DATE ENTERED
ACTIVE DUTY
B. DATE SEPARATED
FROM ACTIVE DUTY
C. BRANCH OF SERVICE OR RESERVE
OR GUARD COMPONENT
D. CHARACTER OF
DISCHARGE
VA FORM
FEB 2020
22-5495
SUPERSEDES VA FORM 22-5495, SEP 2018,
WHICH WILL NOT BE USED.
Page 1
PART IV - BENEFIT AND TYPE OF EDUCATION OR TRAINING
21A. TYPE OF BENEFIT
CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY SERGEANT JOHN DAVID FRY SCHOLARSHIP (FRY SCHOLARSHIP)
CHAPTER 35 - SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE PROGRAM (DEA)
21B. TYPE OF TRAINING
COLLEGE OR OTHER SCHOOL
NATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDIT
FARM COOPERATIVE
CORRESPONDENCE COURSE (DEA Children not eligible)
LICENSING OR CERTIFICATION TEST
FLIGHT TRAINING (Fry Scholarship only)
APPRENTICESHIP OR OTHER ON-THE-JOB TRAINING
22. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE
(e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer)
23. WHAT IS THE NAME OF THE PROGRAM YOU ARE REQUESTING TO PURSUE?
24. IF CHANGING SCHOOLS, PROVIDE NAME AND COMPLETE ADDRESS OF NEW
SCHOOL OR TRAINING ESTABLISHMENT YOU PLAN TO ATTEND (if applicable)
25. IF CHANGING SCHOOLS, PROVIDE NAME AND COMPLETE ADDRESS
OF CURRENT OR OLD SCHOOL OR TRAINING ESTABLISHMENT
26. TELL US WHEN AND WHY YOU STOPPED (or will stop) TRAINING AT YOUR OLD (or current) SCHOOL OR TRAINING ESTABLISHMENT
PART V - REMARKS AND CERTIFICATION
27. 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 of paper)
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.
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.
28A. SIGNATURE OF APPLICANT (DO NOT PRINT)
Sign Here
In INK
28B. DATE SIGNED
VA FORM 22-5495, FEB 2020
Page 2
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 9. 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 Treasury at 1-888-224-2950. They will encourage your participation in EFT and
address any questions or concerns you may have.
INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
DEPENDENTS' REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
(VA FORM 22-5495)
• Survivors' and Dependents' Educational Assistance Program (chapter 35 of title 38, U.S. Code)
• Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship (chapter 33 of title 38, U.S. Code)
Use this form to request a change of program or place of training under the following benefit programs:
Do not use this form to apply for a change of program or place of training for Veterans' education assistance based on your own service
(chapters 30, 32, 33, 1606, or 1607). To apply for a change of program or place of training for Veterans' education assistance benefits based on your own
service, use VA Form 22-1995, Request for Change of Program or Place of Training.
INTERNET VERSION AVAILABLE
VA VOCATIONAL AND EDUCATIONAL COUNSELING HELP AVAILABLE
VA offers a wide range of services to assist you in planning your education 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-
GI-BILL-1 (1-888-442-4551) or if you use the Telecommunications Device for the Deaf (TDD), the Federal Relay number is 711.
These numbers on the instructions match the item numbers on the application. Items not mentioned are self-explanatory.
ITEM 3.
NOTE:
Your VA FILE NUMBER is the number that appears on your VA benefit checks and all mail that we've sent to you. Generally, your VA FILE
NUMBER is the social security number of the individual on whose account you are receiving benefits. Your SUFFIX (letter or 2-digit number) indicates
your relationship to the qualifying individual.
ITEM 9.
ITEM 17. To qualify for Survivors' and Dependents' Educational Assistance (DEA), you must be either-
(1) The spouse or child of a veteran who is permanently or totally disabled as a result of a service-connected disability.
(2) The spouse or child of an individual on active duty who has been listed as missing in action, captured in line of duty by hostile force, forcibly
detained or interned in line of duty by hostile force, or forcibly detained or interned in line of duty by a foreign government or power for more
than 90 days.
(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.
(4) The spouse or 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 serviceperson is likely to be discharged or released from such service for such disability.
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(c)). Additional guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.
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. To qualify for the Fry Scholarship,
you must be the child of an individual who after September 10, 2001, died in the line of duty while serving on active duty as a member of the Armed
Forces.
Select the benefit under which you are applying for a change in program or place of training. Types of education or training programs are
self-explanatory, except for the following:
ITEM 21.
IMPORTANT:
"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 Admissions Exams or
National Exams for Credit." Individuals eligible to receive benefits may be reimbursed for the cost of approved test for admission to or credit at
institutions of higher learning.
"Correspondence." Only spouses and surviving spouses eligible for the Survivors' and Dependents' Educational Assistance program and Fry Scholarship
recipients under the Post-9/11 GI Bill 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, please visit our website at
www.benefits.va.gov/gibill.
"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.
VA FORM 22-5495, FEB 2020
Page 3
You may complete and submit this application on-line at www.benefits.va.gov/gibill. Click on "GI Bill: Apply for Benefits."
We need this information to determine your eligibility for education benefits (38 U.S.C. 3513). Title 38, United States Code, allows us to ask
for this information. We estimate that you will need an average of 15 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.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 information collection.
REQUEST TO OPT-OUT OF INFORMATION SHARING WITH EDUCATIONAL INSTITUTIONS:
HOW TO FILE YOUR CLAIM
Be sure to do the following:
(A) If you have selected a school or training establishment:
Step 2: Tell the veterans certifying official at your school or training establishment that you have applied for VA educational benefits. Ask him or
her to send 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 its decision concerning your eligibility for education benefits.
Step 1: Mail the completed form to the VA Regional Processing Office for the region of that school's physical address. See below for the
addresses of these VA Regional Processing Offices.
(B) If you have not selected a school or training establishment:
Step 1: Mail the completed form to the VA Regional Processing Office for the region of your home address. See below for the address of these
VA Regional Processing Offices.
Step 2: Wait for the VA to process your application and notify you of its decision concerning your eligibility for education benefits.
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
PO Box 4616
Buffalo, NY 14240-4616
CT
DE
DC
MA
MD
ME
NC
NH
NJ
NY
PA
RI
VA
VT
US Virgin Islands
Foreign Schools
APO/FPO AA
CENTRAL REGION
VA Regional Office
PO Box 32432
St. Louis, MO 63132-0832
CO
IL
IN
IA
KS
KY
MI
MN
MO
MT
NE
ND
OH
SD
TN
WI
WV
WY
WESTERN REGION
VA Regional Office
PO Box 8888
Muskogee, OK 74402-8888
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
ADDITIONAL HELP
If you need additional help completing this application or you want information about our work-study program, call VA 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. You can also get more information
about education assistance from our education Internet site at www.benefits.va.gov/gibill.
PRIVACY ACT NOTICE:
RESPONDENT BURDEN:
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 1.526 for routine uses as identified in VA's system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational
Rehabilitation and Employment Records - VA, published in the Federal Register. An example of routine use allows VA to send 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 VA to obtain further
information as may be necessary from the school for VA to properly process the veteran's education claim or to monitor his or her progress during training. 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. Payment of education benefits cannot be made 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.
VA FORM 22-5495, FEB 2020
Page 4
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VA DATE STAMP PART I - APPLICANT INFORMATION (Norco College)

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