Form VA-21-8926 Certification of School Attendance - REPS

OMB Approved No. 2900-0394
Respondent Burden: 15 Minutes

CERTIFICATION OF SCHOOL ATTENDANCE - REPS
IMPORTANT: The certification is requested on behalf of the student named below to determine entitlement to benefits. While you
are not required to respond, your cooperation in promptly completing and returning this form will be appreciated. The form should be
returned to the VA Regional Office (21Q), 400 South 18th Street, St. Louis, MO 63103.
1. NAME AND ADDRESS OF SCHOOL

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, CFR 1.576
for routine uses (i.e., civil or criminal law enforcement,
congressional communications, epidemiological or research
studies, the collection of money owed to the United States,
litigation in which the United States is a party or has an interest,
the administration of VA programs and delivery of VA benefits,
verification of identify and status, and personnel administration) 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 required to obtain or retain benefits. The requested information
is considered relevant and necessary to determine maximum
benefits under the law. 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.

NOTE: REPS represents the Restored Entitlement Program For Survivors.
2. VETERAN’S/WAGE EARNER’S SOCIAL
SECURITY NUMBER

3. STUDENT’S NAME

4. STUDENT’S SOCIAL SECURITY NUMBER

5. ATTENDANCE

COMPLETE ALL ITEMS BELOW
GIVING INFORMATION ONLY
FOR THE PERIOD INDICATED

A. FROM (Month, day, year)

B. TO (Month, day, year)

STUDENT CERTIFICATION
6. DURING THE PERIOD SHOWN IN ITEM 5:
A.
D.
I AM ATTENDING FULL-TIME
I ATTENDED FULL-TIME
ONLY FOR THE PERIOD
B.
I AM NOT ATTENDING
INDICATED IN ITEM 6E
FULL-TIME
(Provide dates of full-time
attendance)
C.
I DID NOT ATTEND

6E. DATES OF FULL-TIME ATTENDANCE INDICATED IN ITEM 6D
FROM (Month, day, year)

TO (Month, day, year)

I CERTIFY THAT the foregoing statement is true and correct to the best of my knowledge and belief.
7A. SIGNATURE OF STUDENT

7B. DATE

CERTIFICATION BY SCHOOL OFFICIAL
8. IS THE STUDENT ENROLLED IN FULL-TIME STATUS ACCORDING TO THE SCHOOL’S STANDARDS AND PRACTICES FOR THE PERIOD
SHOWN IN ITEM 5? (For evening students, use the same standards applicable to day students)
YES

NO (If "No," complete Item 9)

9. ENTER BEGINNING AND ENDING DATES (UP TO THE
PRESENT) OF STUDENT’S FULL-TIME STATUS (If none, enter
"NONE") (If more space is needed, enter additional information in
Item 12, Remarks, and key answers to item numbers)
10. TYPE OF SCHOOL
JUNIOR COLLEGE,
COLLEGE OR
UNIVERSITY

COLLEGE GRADUATE

TO BE COMPLETED BY ALL SCHOOLS
EXCEPT JUNIOR COLLEGES,
COLLEGES OR UNIVERSITIES

TECHNICAL, TRADE
OR VOCATIONAL

A. FROM (Month, day, year)

B. TO (Month, day, year)

OTHER
(Specify)

11. ENTER THE TOTAL CLOCK HOURS PER WEEK THE STUDENT IS/WAS
SCHEDULED TO ATTEND (Show any variation in scheduled attendance in Item 12,
Remarks, and key answers to item numbers)

12. REMARKS

Respondent Burden: We need this information to determine eligibility for REPS for schoolchild (38 U.S.C. 5101). 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.whitehouse.gov/library/omb/OMBINVC.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

I CERTIFY THAT the foregoing statement is true and correct to the best of my knowledge and belief.
13A. SIGNATURE AND TITLE OF SCHOOL OFFICIAL

VA FORM
OCT 2004

21-8926

13B. SCHOOL TELEPHONE
NO.
(Include Area Code)

EXISTING STOCKS OF VA FORM 21-8926, JUL 1999,
WILL BE USED.

13C. DATE