Form 22-1999v Certificate of Delivery of Advance Payment and Enrollmen

OMB Control No. 2900-0325
Respondent Burden: 5 Minutes

CERTIFICATE OF DELIVERY OF ADVANCE
PAYMENT AND ENROLLMENT
(Chapters 30, 32, and 35, Title 38, U.S.C.;
Chapters 1606 and 1607, Title 10, U.S.C., National
Call to Service, and Section 903 of Public Law
96-342)
IMPORTANT
Read these instructions carefully. Complete this form
and return it to VA when delivery of the advance
payment check is made to this student upon registration
for the period of enrollment shown in Item 3. If this
student fails to register within 30 days after the
commencement date of this enrollment period, the
advance payment check must be returned to the
Department of Treasury. If damaged or destroyed,
notify VA immediately.

NAME OF PAYEE

BENEFIT

FILE NO.

PAYEE

MLT

COURSE RO

FACILITY CODE

INSTRUCTIONS
ITEM 1 - Enter the name of this student’s present course or program.
ITEM 2 - For all initial entrances at this school, enter the amount of credit granted for previous training. This must include credit granted for military
service or experience.
ITEM 3 - NO ENTRY REQUIRED. (The data printed in this item is the information furnished by the school with the request for advance payment.)
ITEM 4 - If the information shown in Item 3 is correct, skip to Items 5A and 5B. If any information shown in Item 3 is incorrect, furnish the correct
information in the appropriate column of Item 4.

HOURS. Report total hours and noncredit deficiency hours separately.
TRAINING TIME (TRNG. TIME). Complete only for graduate level students. Select a training time code from the list below.
DAYS PER WEEK. Complete only if you reported clock hours in Hours.

CODES
TRAINING

HOURS

4 - Full Time
3 - 3/4 Time
2 - 1/2 Time
1 - Less than 1/2, more than 1/4
0 - 1/4 or less

S - Semester
Q - Quarter
U - Carnegie Units
D - Deficiency (all or partial)
C, P, or R - Clock
2. AMOUNT OF CREDIT ALLOWED FOR PREVIOUS
TRAINING (Required on first enrollment)

1. ENTER NAME OF CURRENT COURSE OR CURRICULUM

STATUS OF
PROGRAM

BEGINNING
DATE

ENDING
DATE

HOURS

TRNG.
TIME

DAYS
PER
WEEK

ENT.
CHRG

TYPE
TRNG.

TOTAL CHARGES
(In service, or less
than 1/2 time)

3. CURRENT
ENROLLMENT
DATE

TOTAL

4. CHANGES TO
BE ENTERED
BY SCHOOL

DEFIC.

I CERTIFY THAT the above entries are true and the advance payment check was delivered to the student and, if applicable, the 85-15% ratio requirements were met for this student’s
course of study.
PENALTY - willful false reports concerning benefits payable by VA may result in fines or imprisonment or both.
5A. SIGNATURE AND TITLE OF CERTIFYING OFFICIAL

VA FORM
APR 2010

22-1999V

SUPERSEDES VA FORM 22-1999V, MAY 2007,
WHICH WILL NOT BE USED.

5B. DATE SIGNED

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 5, Code of Federal Regulations 1.526 for routine uses (i.e.,
Allowing 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.) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension,
Education and Vocational Rehabilitation and Employment Records - VA, and published in the Federal Register. Your
obligation to respond is required to obtain or retain benefits. While you do not have to respond, VA cannot pay the
student advance payment until we receive the information. The responses you submit are considered confidential (38
U.S.C. 5701). 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 in effect prior to January 1, 1975, and still in effect.
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 the student’s continuing eligibility for educational
benefits and the amount of benefits payable based on school attendance. (38 U.S.C. sections 3680 & 3684) 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 1-888-GI-BILL-1
(1-888-442-4551) to get information on where to send comments or suggestions about this form.

VA FORM 22-1999V, APR 2010