Form VA Form 22-5281 VA Form 22-5281 Application for Refund of Educational Contributions

Form Approved: OMB No. 2900-0261
Respondent Burden: 10 minutes

APPLICATION FOR REFUND OF EDUCATIONAL CONTRIBUTIONS
(VEAP, Chapter 32, Title 38, U.S.C.)
IMPORTANT INSTRUCTIONS - Before completing this form, remember you may be eligible for education benefits under VEAP if you served between the dates of
January 1,1977 through June 30, 1985 and contributed to the fund. If you accept a refund of your contributions, you will forfeit any entitlement you may have earned
under VEAP. To get information about eligibility for VEAP, or for assistance in completing this form, contact your local VA regional processing office (RPO). See the
reverse side of this form for the address of your RPO. If you want a refund, complete and send this form to your RPO at the address shown. If you need additional
information click on Ask a Question and Find Answers, or call toll-free to 1-888-442-4551. This refund is not available to Montgomery GI Bill, 903, and Chapter 32
participants. Partial refunds cannot be made from your fund balance.

PART I - IDENTIFICATION DATA
1. NAME OF APPLICANT

2. SOCIAL SECURITY NO.

5a. MAILING ADDRESS OF APPLICANT

3. BRANCH OF SERVICE

4. VA FILE NO. (If applicable)

5b. PHONE NUMBER
(Include Area Code)

5c.EMAIL ADDRESS

PART II - NOTICE OF DISENROLLMENT AND APPLICATION FOR REFUND
I request to be disenrolled from the POST-VIETNAM ERA VETERANS EDUCATIONAL ASSISTANCE PROGRAM. I
further request a refund of my remaining contributions. I realize that a refund of my contributions will result in forfeiture
of my entitlement to receive educational benefits under this program. However while on active duty, I may enroll again in this
program by establishing a payroll deduction and/or making a lump sum contribution(s) not to exceed a total of $2700, thereby
reestablishing entitlement to educational benefits.
6. REASON FOR DISENROLLMENT
A.

PERSONAL HARDSHIP

B.

EDUCATION COMPLETED

C.

VOCATION OBTAINED

D.

OTHER (Specify)

NOTE: The following signature block is to be completed only by applicants on active duty. Signature of Service Approving Official is
required only upon disenrollment prior to completion of at least 12 monthly contributions to this program.

FOR
APPLICANTS
ON
ACTIVE
DUTY

9. SIGNATURE AND TITLE OF SERVICE APPROVING
OFFICIAL

7. SIGNATURE OF APPLICANT

8. DATE SIGNED

11. LAST ALLOTMENT (Month, year)

12. SIGNATURE OF INSTALLATION FINANCE OFFICER

10. DATE SIGNED

13. DATE SIGNED

NOTE: The following signature block is to be completed only by applicants not on active duty, and must either be notarized by a
Notary Public or certified by a VA official upon the applicants personal appearance and presentation of valid identification at any VA
regional office.
14.SIGNATURE OF APPLICANT

FOR
APPLICANTS
NOT
ON
ACTIVE
DUTY

15. DATE SIGNED

16. SIGNATURE AND TITLE OF VA CERTIFYING OFFICIAL

18. DATE OF DISCHARGE (AS SHOWN ON YOUR DD FORM 214)

Sworn to and subscribed before me this

day of

[SEAL]

,

Notary Public

My commission expires
PART III - CERTIFICATION (FOR VA USE ONLY)
I CERTIFY that I have reviewed this document and that payment of refund is proper.
19. SIGNATURE OF VA REGIONAL OFFICE FINANCE OFFICER

VA FORM
JUL 2007

22-5281

EXISTING STOCKS OF VA FORM 24-5281, NOV 2005,
WILL BE USED.

20. DATE SIGNED

17. DATE SIGNED

To determine the mailing address on where to send this completed form, you should first find your state in the following Regional
jurisdiction tables. Then, mail your complete form to the post office box address for the VA regional office having jurisdiction for
that region.
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

SERVES THE FOLLOWING STATES

SERVES THE FOLLOWING STATES

CT

DE

DC

ME

CO

IA

IL

IN

MD

MA

NH

NJ

KS

KY

MI

MN

NY

OH

PA

RI

MO

MT

NE

ND

VT

VA

WV

Foreign
Schools

SD

TN

WI

WY

Western Region:
VA Regional Office
P.O. Box 8888
Muskogee, OK 74402-8888

Southern Region:
VA Regional Office
P.O. Box 100022
Decatur, GA 30031-7022

SERVES THE FOLLOWING STATES

SERVES THE FOLLOWING STATES

AK

AR

AZ

CA

AL

FL

GA

MS

HI

ID

LA

NM

NC

PR

SC

US Virgin
Islands

NV

OK

OR

Philippines

TX

UT

WA

PRIVACY ACT INFORMATION: 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 1.576 for routine uses i.e., contacting an employer
only to help facilitate the processing of your refund, as identified in the VA system of records, 58VA21/22, Compensation, Pension,
Education and Rehabilitation Records - VA, published in the Federal Register. Your obligation to respond is voluntary. Giving us
your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101. VA will not
deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of
law in effect prior to January 1, 1975, and still in effect. Information submitted is subject to verification through computer matching
programs with other agencies.
RESPONDENT BURDEN: We need this information to properly identify and refund the amount currently being held in the
Post-Vietnam Era Veterans Education Account. Title 38, United States Code, allows us to ask for this information. We estimate that
you will need an average of 10 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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA . If desired, you can call 1-800-827-1000 to get information on
where to send comments or suggestions about this form.