Form 21-674 Request for Approval of School Attendance

OMB Approved No. 2900-0049
Respondent Burden: l5 minutes
I- ADDRESS OF VA OFFICE

REQUEST FOR APPROVAL OF SCHOOL ATTENDANCE
IMPORTANT - Be sure to read the Instructions on the reverse of Copy I before completing this fu
PART I - TO BE COMPLETED BY CLAIMANT (Also sign certification
28. E.MAIL ADDRESS OF VETERAN

2A. FIRST NAME-MTDDLE INITIAL-LAST NAME OF VETERAN (l vpe ot P ûnt)

qe. nRsr ñeuE-MIDDLE INTTIAL-LAST NAME oF

il lq4ll)

3. VA FILE NUMBER

ø/

applicable)

c/css
48. STUDENT'S SOCIAL SECURITY NO

STTJDENT (vcteran's child quendingschool)(lype or print)

5C. DATE OF MARRIAGE

58. HAS STUDENT EVER MARRIED?

5A. DATE OF BIRTH

! vts I
6. ADDRESS OF STUDENT (Nunber and steet or rural route' city
or P.O., State and ZII' Code)

contplete lten 5c)
?A.IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID BY VA
pppÈñoemS pDUCATTONAL ASSISTANCE (DEA), THE FEDERAL EMPLOYEE S COMPENSATION
Àõr on l¡.¡v orHER AcENcY oR PRocRAM oF THE uNtrED STATES GoVERNMENT?

l.rc 1Í"vnr,"

fl vss l-l ¡¡o

0f "Yes,"cotnpleteltens?8and7C.

If "No,"skintoltenSA)

?8. AGENCY NAME

7C. DATE PAYMENTS BEGAN (Month, day, year)

84. NAME AND ADDRESS OF SCHOOL FOR trvHICH APPROVAL IS REQUESTED

88. NAME OR TYPE OF COURSE OF EDUCATION OR TRAININC

9A. OFFIC¡AL BECINNING DATE OF REGULAR TERM
OR COURSE (Monrh, day, Year)

IOA. IS STUDENT EN-

IOC. NUMBEROF
SESSIONS PER WEEK

IOB. SUBJECT FOR WHICH STUDENT IS ENROLLED
(lfother thanfiill-tìme high school or college course)

ROLLED IN A FULL.
TIME HIGH SCHOOL

9C. EXPECTED DATE OF GR.ADUATION
(Month, day, yeal

98, DATE STUDENT STARTED OR EXPECTS TO START
COURSE (Month, day, year)

IOD. HOURS PER

WEEK

OR COLLEGE COURSE?

nvrs n*o

/lf"No-" conDlete
Iíe,ns iLn. tÔC and l0D)
I IB. NAME AND ADDRESS OF SCHOOL ATTENDED LAST TERM

¡ IA. WAS STUDENT ATTENDING ANY
SCHOOL AT END OF LAST SCHOOL TERM?

n v¡s n

*o

ffi'f,:;,,:;{f',"íi'""

I IC. NO. OF SESSIONS
PER WEEK

I ID- HOURS PER WEEK

I IF. ENDINC DATE OF LASTTERM

I IE. BEGINNING DATE OF LAST TERM

pnnf U - STUDENT'S INCOME AND NET WORTH (See Instructions on reverse for when required)
I3. VALUE OF ESTATE
BY
CALENDAR YEI'R (IMPORTANT - Do NOT report VA
INCOME
REPORT
OF
12.

l91gþ\

A. SOURCE

B. RECEIVED
(Nil'OR'I'FOR YIìAR IN WHICH SCHOOI.
'TEIIM BEGINS-SIìE fl'EM 9 ABOYE)

,

C. EXPECTED
( Ilepo r t fo r ye a r lo I I ow n g
that shou'n in (.-olumn R)

A. SAVINGS
(lncluding cash)

EARNINGS FROM

B. SECURITIES, BONDS,
ETC.

ANNUAL SOCIAL
SECURITY

C, REAL ESTATE
(Not your hone)

OTHER

D. ALL OTHER ASSETS

ALL EMPLOYMENT

ANNUITIES
ALL OTHER INCOME

E. TOTAL OF ABOVE

(lntercst, div¡dends, etc)

$

$

I4. REMARKS

PART

III - CERTIFICATION AND AGREEMENT TO BE SICNED BY CLAIMANT
isclaimingbenefitsinhisorherounright.othenvise,thcveteran,

su*iuinespoüse'guardianorcilstodianwiIlsignandalsõenterhisorherrel
from another. Fed.tul Aggl:I-(y^!:Receipt by the student of vA D.pr"d."t Edu..tionul Arsistance (DEA), the Federal pmployees' compensation Act, or benefìt
,U.'s. l"Ë"h"'it-M;inè ecadeny, gur"au of inoìiar Ãiøirs, etc.¡ with ädd-itional compensation payments based on the student's school attendance ts
üñiË

¡í.;fî,
iëËääi'-v rträîiË iniåñiüÑin-.ÏÑ;l;i.e
considered a duólication ofbenefits and is prohibited.

and correct to the best of my knowledge and belief and request approval of the course of education or training
shown above.
I AGREE to notifv the DeDartment ofveterans Affairs immediately of any change in this course of education, transfer to another school, discontinuance ofschool
eãucitiðnãfessiitance, or màniäge friôr to cõmpletion of the course. I understand that continued entitlement to school attendance
ñã";ìurirrté¿ on trtìr rorÁ. eny ueninïs allowed düe to this certification will be discontinued if the student marries, receives VA
Deiendents Education Assistance (DEA) benefits, Ieaves school, or passes away.

åñã";d;;;i;i;Tüü¡;i;
ii;iËil;ffii;i;ñ;üi
I5A. SIGNATURE

I5B. DAYTIME PHONE NO.
(lnclude Area Code)

I5C. EVENINC PHONE NO.
(lnclude Area Code)

I6. RELATIONSHIP TO STUDENT

17.

DAI'E

th'forthewillfulsubmissionofanystatementorevidenceofamateriaIfact,
knowing it to be false.

drp-ziäT' 21-674

2l-674, JUL 2005,
VA FORM
FoRM 2I-(
SUPERSEDES vA
WHICH WILL NOT BE USED

VÀ FILE COPY I

INSTRUCTIONS
NOTE: Read the instructions carefully before completing this form.
How do I complete VA Form 2l-674?
VA Form 2l-674 should be completed by the person receiving or claiming benefìts for a veteran's child who is
at least l8 but under 23 and attending school. The veteran's child should complete the form only ifhe or she has
reached the age of majority and is or will be entitled to receive direct payment of VA benefits. NOTE: The age
of majority is determined by State law; it is age l8 in most states.
Print all answers clearly. For additional space, attach a separate sheet, indicating the item number to which the
answers apply. Make sure to write the veteran's name and VA claim number on any attachments to this form.
Submit the original copy (VA File Copy l) of the completed form to the VA office shown in Item l. If no
address is shown, mail or take it to the nearest VA regional office. Keep Claimant's Copy 2 for your own
records and use the reverse, School Attendance Report, to report to VA any change in the child's status, such as
termination of school attendance or maniage.

PART I

All claimants must complete this part. Answer "Yes" to Item 7A only if Federal Employee's Compensation,
VA Dependents Educational Assistance (DEA), or another Federal Agency (U.S. Service Academy, U.S.
Merchant Marine Academy, Bureau of Indian Affairs, etc.) is paying the student's tuition. Do not answer "Yes"
simply because the student's continuing school attendance has resulted in Social Security benefits.

PART

'

II

Complete this part only if the benefit being claimed or received is disability pension or death pension. Each
income block must be completed. If you do not receive income from a particular source, write "0" or "none" in
the space provided. Do not leave the space blank. Report the gross amounts before you take out deductions for
taxes, insurance, etc.

Section 306 or Old Law Pension (entitlement to pension established before January l, 1979): Complete this
part only y'the VA benefit payable will be death pension, andthere is no surviving spouse entitled to death
pension. Do not complete if the student is a dependent on a veteran's or surviving spouse's award.

Improved Pension: Complete this part showing the student's income. Educational or vocational rehabilitation
expenses are amounts paid by the student for his or her course of post-secondary education or vocational
rehabilitation, including tuition, fees, and materials. If any of these expenses are paid by the student, the
expenses may be deducted from the eamed income of the student. Report the total amount(s) paid and dates of
payment in Item 14, "Remarks."

PART III
This part will be completed by the student only if he or she has reached the age of majority and is claiming
benefits in his or her own right. Otherwise, the veteran, surviving spouse, guardian or custodian will sign and
also enter his or her relationship to the student in Item I 6.

Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has
been authorized under the Privacy Aæof ß74 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e.,

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 identity and status, and personnel
administration) as identified in the VA system of records, 58VA21122, Compensation, Pension, Education, and
Rehabilitation Records - VA, and 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. Giving us your and your dependents' SSN account information is mandatory. Applicants are
required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 U.S.C.
5l0l(cXl). 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 l, 1975, and still in effect. 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.

civil or criminal law enforcement,

Respondent Burden: We need this information to determine entitlement to benefltts for a veteran's child who is
between age l8 and 23 and attending school (38 U.S.C. 104(a)). 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.eov/omb/library/OMBlNV.VA.EPA.html#VA . If desired, you can call l-800-827-1000 to get
information on where to send comments or suggestions about this form.
vA

FORM

2

I

-6?4, SEP 2008

OMB Approved No. 2900-0049
Respondent Burden: l5 minutes

I. ADDRESS OF VA OFFICE

REQUEST FOR APPROVAL OF SCHOOL ATTENDANCE
IMPORTANT - Be sure to read the lnstructions on the reverse ofcoÞy I before completing this form. The form should be completed in duplicâte and signed in Part IIl.
PART I - TO BE COMPLETED BY CLAIMANT (Also sisn certification in Part III)
3, VA FILE NUMBER
28. E-MAIL ADDRESS OF VETEMN ø/
24. FIRST NAME-MIDDLE INITIAL-LAST NAME OF VETERAN (lype or l'rint)
applicable)

c/css
48. STUDENT'S SOCIAL SECURITY NO.

44. FIRST NAME-MIDDLE INITIAL-LAST NAME OF STUDENT (Vereran's child artanding school)(l'ype or prinQ

5C. DATE OF MARRTAGE

58. HAS STUDENT EVER MARRIED?

5A. DATE OF BIRTH

!

"us

flrto

6. ADDRESS OF STUDENT (Number and srcct or rural routc, city
or P.O., State and 7-lP Code)

U"Yur,""ootptete lrem5c)
7A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID BY VA
DEPENDENTS EDUCATIONAL ASSISTANCE (DEA), THE FEDERAL EMPLOYEE'S COMPENSATION
ACT OR ANY OTHER AGENCY OR PROGRAM OF THE UNITED STATES COVERNMENT?

l-l
?8. AGENCY NAME

""s

ll ruo

ilf"Yes."contnlete lte¡ns78and7C. If"No." skipto lten8A)
7C. DATE PAYMENTS BEGAN (Month, day, year)

88. NAME OR TYPE OF COURSE OF EDUCATION OR TRAINING

8A. NAME AND ADDRESS OF SCHOOL FOR WHICH APPROVAL IS REQUESTED

9A. OFFICIAL BECINNING DATEOF REGULARTERM
OR COURSE (Monrh, day, year)

IOA. IS STUDENT EN.

IOB. SUBJECT FOR WHICH STUDENT IS ENROLLED
(lfother thanfull-time high school or college course)

ROLLED IN A FULL.
TIME HICH SCHOOL
OR COLLECE COURSE?

9C. EXPECTED DATE OF GRADUATION
(Month, day, year)

98. DATE STUDENT STARTED OR EXPECTS TO START
COURSE (Month, day, year)

IOC, NUMBEROF
SESSIONS PER WEEK

IOD. HOURS PER

WEEK

lvrs !*o
(lJ "No," com¡tlete

Iiens l0B, l0C and l0l))
I IA. WAS STUDENT ATTENDING ANY
SCHOOL AT END OF LAST SCHOOL TERM?

E tes n *o

I

lB. NAME AND ADDRESS OF SCHOOL ATTENDED LAST TERIV

(["Yæi'con¡terc trcns

I IC. NO. OF SESSIONS
PER }VEEK

12. REPORT OF INCOME
A. SOURCE

I ID. HOURS PER WEEK

I I F. ENDING DATE OF LAST TERM

I IE. BEGINNING DATE OF LAST TERM

PART II - STUDENT'S INCOME AND NET WORTH (See Instructions on reverse for when required)
13. VALUE OF ESTATE
BY CALENDAR YEAR (IMPORTANT - Do NOT report VA benelìts)
B. RECEIVED
(REPOR'I'I;OR YI;AII IN WHI(.'H S("HOOI.
T'IìRM BTìGINS.SI;Iì II'IìM 9 AEOVE)

'

C. EXPECTED

(Re po rr fo r yea r lo I I ou, i n g

,hal shown in Colunn B)

A. SAVINGS
(lncluding cash)

EARNINGS FROM

ALL EMPLOYMENT

B. SECURITIES, BONDS,
ETC.

ANNUAL SOCIAL
SECURITY

C. REAL ESTATE
(No, your hone)

OTHER

D. ALL OTHER ASSETS

ANNUITIES

ALL OTHER INCOME

E, TOTAL OF ABOVE

(l nrerest, dividends, e,c.)
14.

$

$

REMARKS

PART III . CERTIFICATION AND AGREEMENT TO BE SIGNED BY CLAIMANT
NOTE: This part will be completed by the student only if he or she has attâined majority and is claiming benefits in his or her own right. Otherwise, the veteran,
survivins soouse. s.uardian or custodian will sisn and also enter his or her relationship to the student.

ofVA Dependents Educational Assistance (DEA), the Federal Employees'Compensation Act, or benefit from another-Federal Aggncy (U.S.
Serviie Àcademy, U. S. Mercharit Marine Acadeny, Bureau of Indiam Affairs, etc.) with àdditional compensation pâyments based on the student's school attendance is
considered a duplication ofbenefits and is prohibited.
I CERTIFY THÁT the information given above is true and correct to the best ofmy knowledge and beliefand request approval ofthe course ofeducation or training
Receipt by the student

shown above.
I AGREE to notify the Department of Veterans Affairs immediately of any change in this course of education, transfer to another school, discontinuance ofschool
attendance, receipi of Depèndents Educational Assistânce, or manlage prior to cõmpletion of the course. I understand that continued entitlement to school attendance
may be baied on'informaìion I have furnished on this form. Any benèfiis allowed due to this certification will be discontinued ifthe student marries, receives VA
Dependents Education Assistance (DEA) benefìts, leaves school, or passes away.
I5A. SIGNATURE

I58. DAYTIME PHONE NO.
(lnclude Arca Code)

IsC. EVENING PHONE NO

I6. RELATIONSHIP TO STUDENT

17.

DATE

(lnclude Area Code)

PENALTY: Thelawprovidesseverepenaltieswhichincludefineorimprisonment,orboth,forthewillful submissionofânystatementorevidenceofamaterial fact,
knowine it to be false.
VA FORM

sËi;zõòì" 2l-674

SUPERSEDES VA FORM 2I.674. JUL 2005,
WHICH WILL NOT BE USED.

CLAIMANT'S

l$

o"purtment of Veterans Affairs

SCHOOL ATTENDANCE REPORT
(Unscheduled Termination or Change)

INSTRUCTIONS: The appropriate items below should be completed and the form returned to the Department of Veterans Affairs if
course ofeducation or-trainin-g, receives
ihe student whose enrollniént is recorded on the face ofthis form discontinues the approved
-institution
entirely supported by the Federal
VA Dependents' Educational Assistance (DEA) benefits, enters an educational
govemment, or marries prior to completion of the course.
PART I - NOTICE OF TERMINATION OF SCHOOL ATTENDANCE
I

IB. IS THIS THE OFFICIAL ENDING DATE OF REGULAR TERM FOR SUCH COURSE?

A. DATE SCHOOL ATTENDANCE TERMINATED (Month, day, year)

YES (["Yes," conplete ltem 2A)

28. OFFICIAL ENDING DATE OF REGULAR TERM ¡/Monrh, day, year)

2A. BEGINNING DATE OF THE NEXT REGULAR TERM FOLLOTù'ING
TI{E DATE STUDENT DISCONTINUED SCHOOL /Month, day, year)

3.

REASON FOR TERMINATION OF ATTENDANCE

A.

FAILURETOSTARTCOURSEOFTRAINING

E. OTHER(Pleaseexplain)

B. FAILURETO RESUME COURSE
C, COMPLETIONOFCOURSE
D. TRANSFER TO ANOTHER INSTITUTION
(Specify name and address olother institution, ilknown)

4. REASON FOR TERMINATION DUE TO CHANCE IN STATUS

A.

RECEIPT OF VA DEPENDENTS' EDUCATIONAL ASSISTANCE (DEA) BENEFITS

B. RECEIPT OF FEDERAL EMPLOYEES' COMPENSATION ACT (FECA)
C. RECE¡PT OF OTHER FEDERAL BENEFITS lSrcå ¿r,

U.S. Seruice Academy,

U.S. Merchant Marine Acadeny, Bureau ollndian A/fairs, Job Corp, etc

)

4D. DATE OTHER FEDERAL BENEFITS BEGAN (Mozth, day, ycar)

PART II - NOTICE THAT STUDENT MARRIED
58. MARRIED NAME (ffemale sndent)

5C. ADDRESS OF STUDENT (rVo. aud street or rural rou,e , city or P,O., State and ZIP Code)

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.

9. SIGNATURE OF CLAIMANT, GUARD¡AN OR CUSTODIAN

vA FoRM

2

l-674, SEP 2008