Form VA Form 22-5495 VA Form 22-5495 Dependents' Request for Change of Program or Place of Tr

OMB Approved No. 2900-0099
Respondent Burden: 15 Minutes

DRAFT

DEPENDENTS’ REQUEST FOR CHANGE OF PROGRAM
OR PLACE OF TRAINING
(Under Provisions of chapters 33 and 35, of title 38, U.S.C.)
INTERNET VERSION AVAILABLE - You may complete and submit your application online at www.gibill.va.gov

PART I - APPLICANT INFORMATION
1. NAME (First, Middle Initial, Last)

VA DATE STAMP
(For VA Use Only)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. SEX OF APPLICANT

5. DATE OF BIRTH

FEMALE
MALE
6. CURRENT MAILING ADDRESS (Number and street or rural route, city or P.O., State and 9 DIGIT ZIP Code)

7. TELEPHONE NUMBER(S) (Including Area Code)
SECONDARY

PRIMARY

8. E-MAIL ADDRESS (If applicable)

9. DIRECT DEPOSIT (Attach a voided personal check or provide the following information. Direct Deposit not available for DEA benefit payments)

ROUTING OR TRANSIT NUMBER

ACCOUNT TYPE
CHECKING

ACCOUNT NUMBER

SAVINGS

10. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
A. NAME
B. ADDRESS
C. TELEPHONE NUMBER

PART II - QUALIFYING INDIVIDUAL INFORMATION
11. NAME OF INDIVIDUAL ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (First,Middle,Last)

12. SOCIAL SECURITY NUMBER OR VA FILE NUMBER

13. BRANCH OF SERVICE

14. DATE OF BIRTH

16. IS QUALIFYING INDIVIDUAL CURRENTLY ON ACTIVE DUTY

15. DATE OF DEATH OR DATE LISTED AS MIA OR POW

YES

NO

17. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL
SPOUSE
SURVIVING SPOUSE
CHILD
STEPCHILD
ADOPTED CHILD
18. DO YOU OR THE QUALIFYING INDIVIDUAL ON WHOSE ACCOUNT YOU ARE CLAIMING BENEFITS HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
YES

NO

PART III - APPLICANT’S MILITARY SERVICE INFORMATION
(NOTE: Chapter 35 benefits are not payable while an eligible person is on active duty)
19. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES? (If "No," skip to Part IV)
YES

NO

20. INFORMATION ABOUT YOUR PERIOD(S) OF ACTIVE DUTY
A. DATE ENTERED
ACTIVE DUTY

VA FORM
DEC 2009

22-5495

B. DATE SEPARATED
FROM ACTIVE DUTY

C. BRANCH OF SERVICE OR RESERVE
OR GUARD COMPONENT

SUPERSEDES VA FORM 22-5495, JAN 2004,
WHICH WILL NOT BE USED.

D. CHARACTER OF
DISCHARGE

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PART IV - YOUR PROGRAM
21A. CHAPTER 35 - SURVIVORS’ AND DEPENDENTS’ EDUCATIONAL
ASSISTANCE PROGRAM (DEA)

21B. CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY
SERGEANT JOHN DAVID FRY SCHOLARSHIP (FRY SCHOLARSHIP)

COLLEGE OR OTHER SCHOOL

INSTITUTION OF HIGHER LEARNING

FARM COOPERATIVE

LICENSING OR CERTIFICATION TEST

LICENSING OR CERTIFICATION TEST
APPRENTICESHIP OR ON-THE-JOB TRAINING
NATIONAL ADMISSIONS EXAMS OR NATIONAL
EXAMS FOR CREDIT
CORRESPONDENCE (Spouse or Surviving Spouse only)
22. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE (e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer)

23. WHAT IS THE NAME OF THE PROGRAM YOU ARE REQUESTING TO PURSUE?

24. IF CHANGING SCHOOLS, PROVIDE NAME AND COMPLETE ADDRESS OF NEW
SCHOOL OR TRAINING ESTABLISHMENT YOU PLAN TO ATTEND
(If applicable)

25. IF CHANGING SCHOOLS, PROVIDE NAME AND COMPLETE ADDRESS
OF CURRENT OR OLD SCHOOL OR TRAINING ESTABLISHMENT

26. TELL US WHEN AND WHY YOU STOPPED (or will stop) TRAINING AT YOUR OLD (or current) SCHOOL OR TRAINING ESTABLISHMENT

PART V - REMARKS AND CERTIFICATION
27. REMARKS (If more space is needed, please attach a separate sheet of paper. Be sure to include name and social security number on each sheet of paper)

I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.
PENALTY - Willful false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the
forfeiture of these or other benefits and in criminal penalties.
28A. SIGNATURE OF APPLICANT (DO NOT PRINT)

28B. DATE SIGNED

Sign Here
In Ink
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INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
DEPENDENTS’ REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
(VA FORM 22-5495)

..

Use this form to request a change of program or place of training under the following benefit programs:
Survivors’ and Dependents’ Educational Assistance Program (chapter 35 of title 38, U.S. Code)
Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship (chapter 33 of title 38, U.S. Code)
Do not use this form to apply for a change of program or place of training for Veterans’ education assistance based on your own service
(chapters 30, 32, 33, 1606, or 1607). To apply for a change of program or place of training for veterans’ education assistance benefits
based on your own service, use VA Form 22-1995.
INTERNET VERSION AVAILABLE - You may complete and submit this application on-line at www.gibill.va.gov. Click on "GI
Bill: Apply for Benefits."
VA VOCATIONAL AND EDUCATIONAL COUNSELING HELP AVAILABLE - VA offers a wide range of services to assist you
in planning your educational and/or career goals. Services include educational and vocational guidance and testing to develop a greater
understanding of your skills, talents, and interests. For more information on VA counseling, call VA toll-free at 1-888-GI-BILL-1
(1-888-442-4551) or TDD at 1-800-829-4833.
NOTE: The numbers on the instructions match the item numbers on the application. Items not mentioned are self-explanatory.
ITEM 3. Your VA FILE NUMBER is the number that appears on your VA benefit checks and all mail that we’ve sent to you.
Generally, your VA FILE NUMBER is the social security number of the individual on whose account you are receiving benefits. Your
SUFFIX (letter or 2-digit number) indicates your relationship to the qualifying individual.
ITEM 17. To qualify for Survivors’ and Dependents’ Educational Assistance (DEA), you must be either (1) The spouse or child of a veteran who is permanently and totally disabled as a result of a
service-connected disability.
(2) The spouse or child of an individual on active duty who has been listed as missing in action,
captured in line of duty by hostile force, forcibly detained or interned in line of duty by hostile
force, or forcibly detained or interned in line of duty by foreign government or power for more
than 90 days.
(3) The surviving spouse or child of a veteran who died of a service-connected disability or who
dies while a service-connected disability was rated permanent and total in nature.
(4) The spouse or child of an individual on active duty for which the evidence shows that the
individual is hospitalized for receiving outpatient medical care services or treatment; has a
total disability permanent in nature incurred or aggravated in the line of duty in the active
military, naval, or air service; and the serviceperson is likely to be discharged or released
from such service for such disability.
Eligibility for DEA will be terminated in the event that VA determines that the individual on who account benefits are claimed is no
longer totally disabled or VA is notified that the individual is no longer listed as captured, missing in action, or forcibly detained.
To qualify for the Fry Scholarship, you must be the child of an individual who after September 10, 2001, died in the line of duty while
serving on active duty as a member of the Armed Forces.
ITEM 21. Select the benefit under which you are applying for a change in program or place of training. Types of education or training
programs are self-explanatory, except for the following "Licensing or Certification Test." A licensing test is a test offered by a state, local, or federal agency that is required by law to practice an
occupation. A certification test is a test designed to provide affirmation of an individual’s qualifications in a specific occupation.
"National Admission Exam or National Exam for Credit." Individuals eligible to receive benefits under the Survivors’ and Dependents’
Educational Assistance program may be reimbursed for the cost of approved tests for admission to or credit at institutions of higher
learning.
"Correspondence." Only spouses and surviving spouses eligible for the Survivors’ and Dependents’ Educational Assistance program may
receive benefits for correspondence training. Payments for correspondence courses are made quarterly after
VA receives a certification showing the number of lessons completed. For more information on correspondence courses, please visit our
website at www.gibill.va.gov.

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HOW TO FILE YOUR CLAIM
Be sure to do the following:
(A) If you have selected a school or training establishment:
Step 1: Mail the completed form to the VA Regional Processing Office for the region of that school’s physical address.
See below for the addresses of these VA Regional Processing Offices.
Step 2: Tell the veterans certifying official at your school or training establishment that you have applied for VA
education benefits. Ask him or her to send your enrollment information using VA Form 22-1999, Enrollment
Certification, or its electronic version.
Step 3: Wait for VA to process your application and notify you of its decision concerning your eligibility for education
benefits.
(B) If you have not selected a school or training establishment:
Step 1: Mail the completed form to the VA Regional Processing Office for the region of your home address. See
below for the addresses of these VA Regional Processing Offices.
Step 2: Wait for VA to process your application and notify you of its decision concerning your eligibility for education
benefits.
Eastern Region:
Central Region:
VA Regional Office
VA Regional Office
P. O. Box 4616
P. O. Box 66830
Buffalo, NY 14240-4616
St. Louis, MO 63166-6830
SERVES THE FOLLOWING STATES

CT
MD
NY
VT

DE
MA
OH
VA

DC
NH
PA
WV

SERVES THE FOLLOWING STATES

ME
NJ
RI
Foreign Schools

CO
KS
MO
SD

Western Region:
VA Regional Office
P. O. Box 8888
Muskogee, OK 74402-8888
AR
ID
OK
UT

AZ
LA
OR
WA

IL
MI
NE
WI

IN
MN
ND
WY

Southern Region:
VA Regional Office
P. O. Box 100022
Decatur, GA 30031-7022

SERVES THE FOLLOWING STATES

AK
HI
NV
TX

IA
KY
MT
TN

SERVES THE FOLLOWING STATES

CA
NM
Philippines
GUAM

AL
NC

FL
PR
APO/FPO AA

GA
SC

MS
US Virgin
Islands

APO/FPO AP

MORE HELP - If you need more help completing this application or you want information about our work-study program, call VA
toll-free at 1-888-GI-BILL-1 (1-888-442-4551). If you are hearing impaired, call us toll-free at 1-800-829-4833. You can also get more
information about education assistance from our education Internet site at www.gibill.va.gov.
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 1.526 for routine uses as identified in VA’s system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and
Employment Records - VA, published in the Federal Register. An example of routine use allows VA to send 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 VA to obtain further information as may be necessary from the
school for VA to properly process the veteran’s education claim or to monitor his or her progress during training. Your obligation to respond is required to obtain or retain
education benefits. The requested information is considered relevant and necessary to determine the maximum benefits under the law. Payment of education benefits cannot be
made unless the information is furnished as required by existing law (38 U.S.C. 3513). The responses you submit are considered confidential (38 U.S.C. 5701). Information that is
submitted is 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. 3513). 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 1-888-GI-BILL-1
(1-888-442-4551) to get information on where to send comments or suggestions about this information collection.

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