Fillable VBA 22 5495 Dependents Request Change Program Place Training (North Central Texas College)

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VBA 22 5495 Dependents Request Change Program Place Training (North Central Texas College)

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PART I - APPLICANT INFORMATION
PART II - QUALIFYING INDIVIDUAL INFORMATION
PART III - APPLICANT'S MILITARY SERVICE INFORMATION
(NOTE: Chapter 35 benefits are not payable while an eligible person is an active duty)
22-5495
DEPENDENTS' REQUEST FOR CHANGE OF PROGRAM
OR PLACE OF TRAINING
(Under Provisions of Chapters 33 and 35, Title 38, U.S.C.)
SUPERSEDES VA FORM 22-5495, OCT 2011,
WHICH WILL NOT BE USED.
VA FORM
JUL 2012
VA DATE STAMP
(For VA Use Only)
SURVIVING SPOUSE STEPCHILD
6. CURRENT MAILING ADDRESS
(Number and street or rural route, city or P.O., State and 9 DIGIT ZIP Code)
SECONDARY
5. DATE OF BIRTH
OMB Approved No. 2900-0099
Respondent Burden: 15 Minutes
1. NAME (First, Middle Initial, Last)
11. NAME OF INDIVIDUAL ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (First, Middle, Last)
8. E-MAIL ADDRESS (if applicable)
NO
YES
INTERNET VERSION AVAILABLE - You may complete and submit your application online at www.gibill.va.gov
3. VA FILE NUMBER2. SOCIAL SECURITY NUMBER
4. SEX OF APPLICANT
7. TELEPHONE NUMBER(S)
(Including Area Code)
17. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL
PRIMARY
15. DATE OF DEATH OR DATE LISTED AS MIA OR POW
CHILDSPOUSE ADOPTED CHILD
12. SOCIAL SECURITY NUMBER OR VA FILE NUMBER
14. DATE OF BIRTH
19. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES?
(If "No," skip to Part IV)
13. BRANCH OF SERVICE
MALE FEMALE
20. INFORMATION ABOUT YOUR PERIODS OF ACTIVE DUTY
D. CHARACTER OF
DISCHARGE
A. DATE ENTERED
ACTIVE DUTY
C. BRANCH OF SERVICE OR RESERVE
OR GUARD COMPONENT
B. DATE SEPARATED
FROM ACTIVE DUTY
Page 1
9. DIRECT DEPOSIT (Attach a voided personal check or provide the following information. Direct Deposit not available for DEA benefit payments)
ROUTING OR TRANSIT NUMBER
ACCOUNT TYPE
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
16. IS QUALIFYING INDIVIDUAL CURRENTLY ON ACTIVE DUTY
YES NO
18. DO YOU OR THE QUALIFYING INDIVIDUAL ON WHOSE ACCOUNT YOU ARE CLAIMING BENEFITS HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
NOYES
CHECKING SAVINGS
PART V - REMARKS AND CERTIFICATION
PART IV - BENEFIT AND TYPE OF EDUCATION OR TRAINING
28A. SIGNATURE OF APPLICANT (DO NOT PRINT) 28B. DATE SIGNED
23. WHAT IS THE NAME OF THE PROGRAM YOU ARE REQUESTING TO PURSUE?
22. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE
(e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer)
26. TELL US WHEN AND WHY YOU STOPPED (or will stop) TRAINING AT YOUR OLD (or current) SCHOOL OR TRAINING ESTABLISHMENT
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.
Page 2
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
Sign Here
In INK
VA FORM 22-5495, JUL 2012
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
APPRENTICESHIP OR OTHER ON-THE-JOB TRAINING
FARM COOPERATIVE
LICENSING OR CERTIFICATION TEST
NATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDIT
CORRESPONDENCE COURSE (DEA Children not eligible)
FLIGHT TRAINING (Fry Scholarship only)
INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
DEPENDENTS' REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
(VA FORM 22-5495)
Use this form to request a change of program or place of training under the following benefit programs:
• 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)
INTERNET VERSION AVAILABLE- You may complete and submit this application on-line at www.gibill.va.gov. Click on "GI Bill:
Apply for Benefits."
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.
NOTE: These numbers on the instructions match the item numbers on the application. Items not mentioned are self-explanatory.
ITEM 3. 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.
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.
Page 3
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.
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.
ITEM 21. 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-
"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.gibill.va.gov.
"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, JUL 2012
NV
Eastern Region:
VA Regional Office
P. O. Box 4616
Buffalo, NY 14240-4616
Central Region:
VA Regional Office
P. O. Box 66830
St. Louis, MO 63166-6830
Western Region:
VA Regional Office
P. O. Box 8888
Muskogee, OK 74402-8888
PRIVACY ACT NOTICE: 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 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.
RESPONDENT BURDEN: 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 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 information collection.
VT
SERVES THE FOLLOWING STATES
SERVES THE FOLLOWING STATES SERVES THE FOLLOWING STATES
ME
NJ
IN
DE DC
SERVES THE FOLLOWING STATES
CA
MA NH
NY
PA RI
VA
Foreign Schools
CT
MN
IA
ILCO
ND
KY
MI
WV
MO
MT
NE
KS
OH
SD
MD
MS
OR
AK
UT
HI
NM
AL
US Virgin IslandsID
AR
PR
LA
AZ
OK
FL GA
NC SC
HOW TO FILE YOUR CLAIM
Be sure to do the following:
(A) If you have selected a school or training establishment:
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.
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.
(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.
Southern Region:
VA Regional Office
P. O. Box 100022
Decatur, GA 30031-7022
TN
TX
Page 4
WA
APO/FPO AP
APO/FPO AA
MORE HELP - If you need more 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.gibill.va.gov.
VA FORM 22-5495, JUL 2012
Philippines Guam
WI WY
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VBA 22 5495 Dependents Request Change Program Place Training (North Central Texas College)

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