21-674C Request for Approval of School Attendance

VA FORM
SEP 2008

21-674c

SUPERSEDES VA FORM 21-674c, JUL 2005,
WHICH WILL NOT BE USED.

OMB Approved No. 2900-0049
Respondent Burden: 15 minutes
1. ADDRESS OF VA OFFICE

REQUEST FOR APPROVAL OF SCHOOL ATTENDANCE
IMPORTANT: Be sure to read the Instructions on the reverse of VA File Copy 1 before completing
this form. This form should be completed in duplicate and signed in Part III. Return the original (VA
File Copy) to the VA Office shown in Item 1. The copy will be retained by the claimant.
PART I - TO BE COMPLETED BY CLAIMANT (Also sign certification in Part III)
2A. FIRST NAME-MIDDLE INITIAL-LAST NAME OF VETERAN (Type or print)

3. VA FILE NUMBER

C/CSS
2B. E-MAIL ADDRESS OF VETERAN (If applicable)

4A. STUDENT’S SOCIAL SECURITY NUMBER

4B. FIRST NAME-MIDDLE INITIAL-LAST NAME OF STUDENT (Veteran’s child attending
school) (Type or print)
5A. DATE OF BIRTH

5B. HAS STUDENT EVER MARRIED?

YES
6. ADDRESS OF STUDENT (Number and street or rural route,
city or P.O., State and ZIP Code)

5C. DATE OF MARRIAGE

(If "Yes," complete Item 5C)
NO
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 PEOGRAN OF THE UNITED STATES GOVERNMENT?
YES

7B. AGENCY NAME

NO (If "Yes," complete Items 7B and 7C. If "No," skip to Item 8A)
7C. DATE PAYMENTS BEGAN (Month, day, year)

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

9A. OFFICIAL BEGINNING DATE OF REGULAR TERM
OR COURSE
10A. IS STUDENT
ENROLLED IN FULL-TIME
HIGH SCHOOL OR
COLLEGE COURSE?

8B. NAME OR TYPE OF COURSE OF EDUCATION OR TRAINING

9B. DATE STUDENT STARTED OR EXPECTS TO START
COURSE (Month, day, year)

10B. SUBJECT FOR WHICH STUDENT IS ENROLLED
(If other than full-time high school or college course)

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

10C. NUMBER OF
SESSIONS PER WEEK

10D. HOURS PER WEEK

YES
NO
(If "No," complete Items
10B, 10C and 10D)
11A. WAS STUDENT ATTENDING ANY SCHOOL
11B. NAME AND ADDRESS OF SCHOOL ATTENDED LAST TERM
AT END OF LAST SCHOOL TERM?
YES
NO (If "Yes," complete Items 11B through 11F)
11C. NO. OF SESSIONS
11E. BEGINNING DATE OF LAST TERM
11F. ENDING DATE OF LAST TERM
11D. HOURS PER WEEK
PER WEEK

PART II - STUDENT’S INCOME AND NET WORTH (See Instructions for when required)
13. VALUE OF ESTATE
12. REPORT OF INCOME BY CALENDAR YEAR (IMPORTANT - Do NOT report VA benefits)
B. RECEIVED
C. EXPECTED
A. SOURCE
(REPORT FOR YEAR IN WHICH SCHOOL (Report for year following that A. SAVINGS (Including cash)
$
TERM BEGINS-SEE ITEM 9 ABOVE)
shown in column B)
EARNINGS FROM ALL
B. SECURITIES, BONDS,
ETC.
EMPLOYMENT
ANNUAL SOCIAL
C. REAL ESTATE
SECURITY
(Not your home)
OTHER ANNUITIES

D. ALL OTHER ASSETS

ALL OTHER INCOME
(Interest, dividends, etc.)
14. REMARKS

E. TOTAL OF ABOVE

$

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 attained 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.

Receipt by the student of VA Dependents Educational Assistance (DEA), the Federal Employees’ Compensation Act, or benefit from another Federal Agency (U.S.
Service Academy, U. S. Merchant Marine Acadeny, Bureau of Indiam Affairs, etc.) with additional compensation payments based on the student’s school attendance is
considered a duplication of benefits and is prohibited.
I CERTIFY THAT the information given above is true 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 notify the Department of Veterans Affairs immediately of any change in this course of education, transfer to another school, discontinuance of school
attendance, receipt of Dependents Educational Assistance, or marriage prior to completion of the course. I understand that continued entitlement to school attendance
may be based on information I have furnished on this form. Any benefits allowed due to this certification will be discontinued if the student marries, receives VA
Dependents Education Assistance (DEA) benefits, leaves school, or passes away.
15A. SIGNATURE

15B. DAYTIME PHONE NO.
(Include Area Code)

15C. EVENING PHONE NO.
(Include Area Code)

16. RELATIONSHIP TO
STUDENT

17. DATE

Penalty: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or
evidence of a material fact, knowing it to be false.
VA FORM
SEP 2008

21-674c

SUPERSEDES VA FORM 21-674c, JUL 2005,
WHICH WILL NOT BE USED.

VA FILE COPY 1

INSTRUCTIONS
NOTE: Read the instructions carefully before completing this form.
How do I complete VA Form 21-674c?
VA Form 21-674c should be completed by the person receiving or claiming benefits for a veteran’s child who is at
least 18 but under 23 and attending school. The veteran’s child should complete the form only if he 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 18 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 1) of the completed form to the VA office shown in Item 1. 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 marriage.
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 1, 1979): Complete this part
only if the VA benefit payable will be death pension, and there 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 earned 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 16.
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 1.576 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 identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22, 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. 5101(c)(1). 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. 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 entitlement to benefits for a veteran’s child who is between age 18 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.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.
VA FORM 21-674c, SEP 2008

OMB Approved No. 2900-0049
Respondent Burden: 15 minutes
1. ADDRESS OF VA OFFICE

REQUEST FOR APPROVAL OF SCHOOL ATTENDANCE
IMPORTANT: Be sure to read the Instructions on the reverse of VA File Copy 1 before completing
this form. This form should be completed in duplicate and signed in Part III. Return the original (VA
File Copy) to the VA Office shown in Item 1. The copy will be retained by the claimant.
PART I - TO BE COMPLETED BY CLAIMANT (Also sign certification in Part III)
2A. FIRST NAME-MIDDLE INITIAL-LAST NAME OF VETERAN (Type or print)

3. VA FILE NUMBER

C/CSS
2B. E-MAIL ADDRESS OF VETERAN (If applicable)

4A. STUDENT’S SOCIAL SECURITY NUMBER

4B. FIRST NAME-MIDDLE INITIAL-LAST NAME OF STUDENT (Veteran’s child attending
school) (Type or print)
5A. DATE OF BIRTH

5B. HAS STUDENT EVER MARRIED?

YES
6. ADDRESS OF STUDENT (Number and street or rural route,
city or P.O., State and ZIP Code)

5C. DATE OF MARRIAGE

(If "Yes," complete Item 5C)
NO
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 PEOGRAN OF THE UNITED STATES GOVERNMENT?
YES

7B. AGENCY NAME

NO (If "Yes," complete Items 7B and 7C. If "No," skip to Item 8A)
7C. DATE PAYMENTS BEGAN (Month, day, year)

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

9A. OFFICIAL BEGINNING DATE OF REGULAR TERM
OR COURSE
10A. IS STUDENT
ENROLLED IN FULL-TIME
HIGH SCHOOL OR
COLLEGE COURSE?

8B. NAME OR TYPE OF COURSE OF EDUCATION OR TRAINING

9B. DATE STUDENT STARTED OR EXPECTS TO START
COURSE (Month, day, year)

10B. SUBJECT FOR WHICH STUDENT IS ENROLLED
(If other than full-time high school or college course)

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

10C. NUMBER OF
SESSIONS PER WEEK

10D. HOURS PER WEEK

YES
NO
(If "No," complete Items
10B, 10C and 10D)
11A. WAS STUDENT ATTENDING ANY SCHOOL
11B. NAME AND ADDRESS OF SCHOOL ATTENDED LAST TERM
AT END OF LAST SCHOOL TERM?
YES
NO (If "Yes," complete Items 11B through 11F)
11C. NO. OF SESSIONS
11E. BEGINNING DATE OF LAST TERM
11F. ENDING DATE OF LAST TERM
11D. HOURS PER WEEK
PER WEEK

PART II - STUDENT’S INCOME AND NET WORTH (See Instructions for when required)
13. VALUE OF ESTATE
12. REPORT OF INCOME BY CALENDAR YEAR (IMPORTANT - Do NOT report VA benefits)
B. RECEIVED
C. EXPECTED
A. SOURCE
(REPORT FOR YEAR IN WHICH SCHOOL (Report for year following that A. SAVINGS (Including cash)
$
TERM BEGINS-SEE ITEM 9 ABOVE)
shown in column B)
EARNINGS FROM ALL
B. SECURITIES, BONDS,
ETC.
EMPLOYMENT
ANNUAL SOCIAL
C. REAL ESTATE
SECURITY
(Not your home)
OTHER ANNUITIES

D. ALL OTHER ASSETS

ALL OTHER INCOME
(Interest, dividends, etc.)
14. REMARKS

E. TOTAL OF ABOVE

$

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 attained 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.

Receipt by the student of VA Dependents Educational Assistance (DEA), the Federal Employees’ Compensation Act, or benefit from another Federal Agency (U.S.
Service Academy, U. S. Merchant Marine Acadeny, Bureau of Indiam Affairs, etc.) with additional compensation payments based on the student’s school attendance is
considered a duplication of benefits and is prohibited.
I CERTIFY THAT the information given above is true 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 notify the Department of Veterans Affairs immediately of any change in this course of education, transfer to another school, discontinuance of school
attendance, receipt of Dependents Educational Assistance, or marriage prior to completion of the course. I understand that continued entitlement to school attendance
may be based on information I have furnished on this form. Any benefits allowed due to this certification will be discontinued if the student marries, receives VA
Dependents Education Assistance (DEA) benefits, leaves school, or passes away.
15A. SIGNATURE

15B. DAYTIME PHONE NO.
(Include Area Code)

15C. EVENING PHONE NO.
(Include Area Code)

16. RELATIONSHIP TO
STUDENT

17. DATE

Penalty: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or
evidence of a material fact, knowing it to be false.
VA FORM
SEP 2008

21-674c

SUPERSEDES VA FORM 21-674c, JUL 2005,
WHICH WILL NOT BE USED.

CLAIMANT’S COPY 2

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 the student whose enrollment is recorded on the face of
this form discontinues the approved course of education or
training, receives VA Dependents’ Educational Assistance (DEA)
benefits, enters an educational institution entirely supported by
the Federal government, or marries prior to completion of the
course.
PART I - NOTICE OF TERMINATION OF SCHOOL ATTENDANCE
1A. DATE SCHOOL ATTENDANCE TERMINATED (Month, day, year)

1B. IS THIS THE OFFICIAL ENDING DATE OF REGULAR TERM FOR SUCH COURSE?

YES (If "Yes," complete Item 2A)
NO (If "No," complete Item 2B)
2A. BEGINNING DATE OF THE NEXT REGULAR TERM FOLLOWING
THE DATE STUDENT DISCONTINUED SCHOOL (Month, day, year)

2B. OFFICIAL ENDING DATE OF REGULAR TERM (Month, day, year)

3. REASON FOR TERMINATION OF ATTENDANCE

E. OTHER (Please explain)

A. FAILURE TO START COURSE OR TRAINING
B. FAILURE TO RESUME COURSE
C. COMPLETION OF COURSE
D. TRANSFER TO ANOTHER INSTITUTION
(Specify name and address of other institution, if known)

4. REASON FOR TERMINATION DUE TO CHANGE IN STATUS

A. RECEIPT OF VA DEPENDENTS’ EDUCATIONAL ASSISTANCE (DEA) BENEFTIS
B. RECEIPT OF FEDERAL EMPLOYEES’ COMPENSATION ACT (FECA)
C. RECEPT OF OTHER FEDERAL BENEFITS (Such as, U.S. Service Academy,
U.S. Merchant Marine Academy, Bureau of Indian Affairs, Job Corp, etc.)
4D. DATE OTHER FEDERAL BENEFITS BEGAN (Month, day, year)

PART II - NOTICE THAT STUDENT MARRIED
5A. DATE OF MARRIAGE

5B. MARRIED NAME (If female student)

5C. ADDRESS OF STUDENT (No. and street or rural route, city or P.O., State and
ZIP Code)

6. REMARKS

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

8. DATE

9A. SIGNATURE OF CLAIMANT, GUARDIAN OR
CUSTODIAN

9B. DAYTIME PHONE NO.
(Include Area Code)

9C. EVENING PHONE NO.
(Include Area Code)

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statements or evidence of a material fact, knowing it to be false.
VA FORM 21-674c, SEP 2008