Form 0918a Certification of United States Paralympics Training Stat

OMB Number:
Respondent Burden: 5 minutes

CERTIFICATION OF UNITED STATES PARALYMPICS TRAINING STATUS
PRIVACY ACT: The information requested on this form is solicited under the authority of Title 38, U.S.C., and Sections 1710, 1712, and 1722. It is
being collected to enable us to determine your eligibility for benefits and will be used for that purpose. The information you supply may be verified
through a computer matching program at any time and information may be disclosed outside the VA as permitted by law. VA may make a routine use
disclosure of the information as outlined in the Privacy Act system of records identified as 58VA21/22/28, Compensation, Pension, Education and
Rehabilitation Records. Your obligation to respond is voluntary; however, the information is required in order for us to determine your eligibility for
the benefit for which you have applied. Failure to furnish the information will have no adverse affect on any other benefits to which you may be
entitled.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond
to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this
application will average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.

SECTION A - IDENTIFYING DATA
1. NAME AND MAILING ADDRESS OF APPLICANT

.

2. VA FILE NUMBER (If applicable)

.

3. VETERANS SOCIAL SECURITY NO.
(Last 4-digits only)

SECTION B - CERTIFICATION OF TRAINING STATUS
4. NAME OF SPORT
5. LOCATION OF TRAINING

6A. BEGINNING
DATE

6B. ENDING
DATE

SECTION C - PERIOD OF ENROLLMENT
6C. LENGTH OF TRAINING
(Daily, Weekly, Monthly, Quarterly)

6D. TYPE OF TRAINING
TRAINING

COMPETITION

RESIDENCE

TRAINING

COMPETITION

RESIDENCE

TRAINING

COMPETITION

RESIDENCE

TRAINING

COMPETITION

RESIDENCE

SECTION D - CERTIFICATION OF ATTENDANCE
(Applicants must be invited to participate in Paralympics training by the United States Paralympics to receive a VA allowance)
7. I certify that the individual in Item 1 began or resumed the training program listed in Section B for the period specified under Section
C. Furthermore, I certify that I will notify the Department of Veterans Affairs, Office of National Veterans Sports Programs and Special
Events, within 3 working days of a change in the individual's training status.
8A. NAME, TITLE, AND SIGNATURE OF DESIGNATED CERTIFYING OFFICIAL

8B. DATE SIGNED

SECTION E - CERTIFICATION OF MARITAL AND DEPENDENT STATUS
9. I certify that information submitted on my application, VA Form 0918b, regarding my marital and dependent status is current and
valid. Furthermore, I certify that I will notify the Department of Veterans Affairs, Office of National Veterans Sports Programs and
Special Events, within 14 business days of a change in my marital or dependent status.
10A. PRINTED NAME AND SIGNATURE OF VETERAN

VA FORM
DEC 2010

0918a

10B. DATE SIGNED