Form VA Form 22-0839 VA Form 22-0839 Yellow Ribbon Program Agreement

OMB Control No. 2900-XXXX
Respondent Burden: 10 minutes

YELLOW RIBBON PROGRAM AGREEMENT
NOTE - PLEASE READ RESPONDENT BURDEN INFORMATION ON REVERSE.
NAME OF INSTITUTION OF HIGHER LEARNING

FACILITY CODE

ADDRESS OF INSTITUTION OF HIGHER LEARNING

VA DATE STAMP
( FOR VA USE ONLY)

The above named institution of higher learning (IHL) agrees to participate in the Yellow Ribbon Program under the
Post-9/11 GI Bill (authorized under title V of Public Law 110-252) subject to the terms, conditions, and representations
provided in this agreement and applicable VA regulations.
1. The IHL agrees to make contributions under the Yellow Ribbon Program by waiving _______ percent of unmet
established charges (i.e., amount of the IHL’s established charges that exceed the maximum educational assistance
payable for tuition and fees under the Post-9/11 GI Bill for an individual in the particular State in which the individual
is enrolled) for each Yellow Ribbon participant during the specified academic year. VA will match the amount waived
by the school, up to 50 percent of the amount of the unmet established charges.
2. The IHL agrees to provide Yellow Ribbon contributions for up to _______ eligible individuals during the specified
(number)
academic year.
3. The IHL agrees to provide contributions for the entire academic year specified in paragraph 5 of this agreement on
a first-come-first-served basis to eligible individuals applying for the Yellow Ribbon Program, regardless of the rate at
which the eligible individual (participant) pursues training or intends to pursue training.
4. The IHL agrees to submit and maintain enrollment certifications, in accordance with applicable VA regulations, for
each eligible individual selected to participate in the program.
5. The terms of this agreement are effective for the academic year (not to exceed 12 months) from ______________ to
(mm/dd/yyyy)
_______________.
(mm/dd/yyyy)

6. This agreement may be amended only upon the written approval of both parties. In the event that the amendment of
this agreement results in the termination of the IHL’s participation in the Yellow Ribbon Program during the
specified academic year, the IHL must give prior notice to each individual who would be affected by such termination
and provide VA with copies of each such notice. Furthermore, any such termination shall not affect any contribution
made prior to the effective date of termination.
7. This agreement is entered into under authority of section 3317 of title 38, United States Code (as added by section
5003 of Public Law 110-252, effective August 1, 2009), and will become effective on the later of August 1, 2009,
or the date of acceptance by a duly authorized officer of VA.
8. The terms of this agreement will be available for public viewing via VA’s GI Bill website at www.GIBILL.va.gov .
9. Completed agreements (with the original signature of an official legally authorized to bind the IHL to this agreement)
must be received by VA no later than Februrary 15 of each calendar year for the following academic year.
Late agreements will not be accepted.
AGREED TO:
SIGNATURE OF AUTHORIZING OFFICIAL

TITLE OF AUTHORIZING OFFICIAL

TELEPHONE NUMBER

FOR VA USE ONLY
ACCEPTED BY:
SIGNATURE OF VA OFFICIAL

VA FORM
NOV 2008

22-0839

DATE SIGNED

DATE ENTERED IN WEAMS

DATE SIGNED

RESPONDENT BURDEN: We need this information to determine your institution of higher learning’s eligibility to
participate in the Yellow Ribbon Program. Title 38 United States Code allows us to request this information. We
estimate that you will need an average of 10 minutes to review the instructions, find information, and complete the
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 . You may also call 1-888-GIBILL-1 (1-888-442-4551)
to get information on where to send comments or suggestions about this information collection.