Form VA Form 22-0830 VA Form 22-0830 Agreement For Release Of VA Education Information To Thi

OMB Approved No. 2900-XXXX
Respondent Burden: 5 minutes

AGREEMENT FOR RELEASE OF VA EDUCATION INFORMATION
TO THIRD PARTY
Claim file #____________________________________ Your Social Security Number _________________________
I,_______________________________________________________ , give permission for ______________________
(Enter your name)

_______________________________________________________________________________________________
(Enter the person’s name and relationship to you)

to contact the VA regarding _________________________________________________________________________
(Enter all education benefits or specific issues)

________________________________________________________________________________________________
I want the following issues excluded from release to the above named individual:
________________________________________________________________________________________________
________________________________________________________________________________________________

Please provide a password the person named above must provide to obtain VA education benefit information on your
behalf:
PASSWORD:______________________________________
NOTE TO BENEFICIARY:
This release excludes address and direct deposit changes as well as monthly certification for payment. It includes ONLY
VA education benefits. It excludes health issues and any other VA benefit to which you may be entitled. These particular
issues must be handled personally by you.

I understand that by signing this release, I give the above named individual access to the information as specified which is contained
in my VA education benefit records.
Signature of Beneficiary: _________________________________________________
Date Signed: _______________________ Phone Number (Include Area Code) _________________________________________

VA DATE STAMP
(Do not write in this space)

VA FORM
MAY 2008

22- 0830

IMPORTANT: Mail this form to the appropriate office below, based on where you live.

Eastern Region:
VA Regional Office
P. O. Box 4616
Buffalo, NY 14240-4616
Serves the following states:
CT
MD
NY
VT

DE
MA
OH
VA

DC
NH
PA
WV

ME
NJ
RI
Foreign Schools

IL
MI
NE
WI

IN
MN
ND
WY

AZ
LA
OR
WA

CA
NM
PHILIPPINES
GUAM

Central Region:
VA Regional Office
P. O. Box 66830
St. Louis, MO 63166-6830
Serves the following states:
CO
KS
MO
SD

IA
KY
MT
TN
Western Region:
VA Regional Office
P. O. Box 8888
Muskogee, OK 74402-8888
Serves the following states:

AK
HI
NV
TX

AR
ID
OK
UT
APO/FPO AP
Southern Region:
VA Regional Office
P. O. Box 100022
Decatur, GA 30031-7022

Serves the following states:
AL
NC

FL
PR

GA
SC

MS
US Virgin Islands

APO/FPO AA
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, Code of Federal Regulations, section 1.526 for routine uses (e.g., VA sends 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 the VA to obtain further information as may be necessary
from the school for the VA to properly process the veteran’s education claim or to monitor his or her progress during training) 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 education benefits. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of
benefits. The 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
enacted before January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine the maximum benefits under the law.
While you do not have to respond, VA cannot process your claim for education assistance unless the information is furnished as required by existing law (38 U.S.C.
3471). The responses you submit are considered confidential (38 U.S.C. 5701). Any information provided by applicants, recipients, and others may be 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. 3471). Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 5 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.