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

OMB Approved No. 2900-0099
Burden: 15 Minutes

DEPENDENTS' REQUEST FOR CHANGE OF PROGRAM
OR PLACE OF TRAINING
(Under Provisions of chapters 33 and 35, of title 38, U.S.C.)

ün

INTERNET VERSION AVAILABLE - You mav complete and submit vour application online at www.qibill-va.qov

PART I . APPLICANT INFORMATION
1.

VA DATE STAMP

NAME (Ftrst, M¡ddle lnrt¡al, Last)

(For VA Use Only)
¿. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. SEX OF APPLICANT

5- DATE OF BIRTH

l-l n¡nrc l-l rrr'¡nle
. CURRENT MAILING ADDRESS (Number and streel or rural route, c¡ty or P.O., Sfale and

I

DIGIT ZtP Çode)

7. TELEPHONE NUMBER(S) (lncludins Area Code)
TRIMARY

SECONDARY

L E-MAIL ADDRESS (lf applicable)
. DIRECT DEPOSIT (Attach a voided personal chec4 or prov¡de the following infomation. Direct Depos¡t not available for DEA þeneÍß paymenls)

ROUTING OR TRANSIT

NUMBER

|_.l¡nnnn¡¡¡
1

\.

O. PLEASE PROVIDE

NAME

fl

TYPE

n

ACCOUNT NUMBER

sevr¡rcs ¡¡fl n¡¡¡nn[lnn¡

THE NAME. ADDRESS. AND TELEPHONE NUMBER OF SOMEONE WHO WLL ALWAYS KNOW WHERE YOU CAN BE REACHED
C. TELEPHONE NUMBER
B. ADDRESS

PART
1.

ACCOUNT

cHecrrruo

II'

OUALIFYING INDIVIDUAL INFORMATION

NAME OF INDIVIDUAL ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (F¡Tst,Midd|e,Last)

13. BRANCH OF SERVICE

12, SOC¡AL SECURITY NUMtsER OR VA FILE NUMtsER

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

4. DATE OF BIRTH

6. IS QUALIFYING INDIVIDUAL CURRENTLY ON ACTIVE DUTY

flvEs E

ruo

17 YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL

I

spouse

!

sunvtvr¡¡c

spousE

n

cHrt-o

n

srepcnuo

n

Roopreo cHr-o

18. DO YOU OR THE QUALIFYING INDIVIDUAL ON WHOSE ACCOUNT YOU ARE CLAIMING BENEFITS HAVE AN OUTSTAND¡NG FELONY AND/OR WARRANT?

!ves n uo

PART III . APPLICANT'S MILITARY SERVICE INFORMATION
(NOTE: Chapter 35 benefits áre not payable while an eligible person is on active duty)
9. HAVE YOU EVER SERVED ON ACTIVE DUTY lN THE ARMED FORCES? (rf "No," sr(¡p to Part lv)

fl vrs n

ruo

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

xêå?ffi 22-54s5

B. DATE SEPARATED
FROM ACTIVE DUTY

RESERVE
I

C. BRANCH OF SERVICE OR
oR GUARD COMPONENT

22-5495, JAN 2004,
WHICH W|LL NOT BE USED,

D. CHARACTER OF
OISCHARGE

Page'1

I
'

21A' CHAPTER 35 . sUT{VIVUKì

'

Ass,stRNcE PRoGRAM (DEA)

n
n

!
!
!
!
!

coLLEGEoRorHERscHooL

!

coRREsPoNDENCE (spouse or SuNiving spouse only)

FARM cooPERATtvE

LrcENsrNG oR cERTtFtcATtoN

SERGEANT JOHN DAVID FRY SCHOLARSHIP (FRY SCHOLARSHIP)

rNsrrurtoN oF HTGHER

LEARNINc

ucENSrNc oR cERTtFtcATtoN TEsr

TEsr

AppRENTrcEsHtp oR oN-THE-JoB TRAINING
NATT.NALADMTssToNS EXAMS oR NAT.oNAL
EXAMS FOR CREDIT

or

SCHOOL OR TRAINING ESTABLISHMENT YOU PLAN TO ATTEND
(lf applicable)

CunnErur oR

scHooL oR TRAININc

ESTABLISHMENT

cur¡ty number on each sheet

ate sheet of Paper' Be sure to in

I CERTIFY THAT all statemeql!-i

@

and correct to the best

PENALTY - willful false statements as to a material fact in a claim for education benefits is
forfeiture of these or other benef its and in criminal penalties.

a

punishable offense and may result in the

Page2

INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
OF TRAINING
DEPENDENTS' REQUEST FOR CHANGE OF PROGRAM OR PLACE

(vA

FORM 22-549s)

the following benefit programs:
Use this form to request a change of program or place of training under
title 38, U'S. Code)
Survivors, and Dependetits' gåucãtional Assistance Program (chapter 35 of
post-9/l I GI Bill Marine Gunnery Sergeant John David Fry Scholarship (chapter 33 of title 38, U'S' Code)

.
.

for Veterans' edu^cation assistance based on your own service
Do not use this form to apply for a change of program or place of training
for veterans' education assistance beneflits
(chapters 30,32, 33, rc¡¿',* r ooz). Toãpply foia ctrange of program oi place of training
based on your own service, use VA Form22-1995'

you may complete and submit this application on-line
INTERNET VERSION AVAILABLE -

at www'gibill.va.gov.

click on "GI

Bill: Apply for Benefits'"
offers
vA vocATIoNAL AND EDUCATIONAL couNsELING HBLP AVAILABLE vA

a wide range of services to assist you
guidance
and testing to develop a greater
and vocational
in planning your educational and/or career goals. services include educational
at l-888-GI-BILL-l
toll-free
vA
on VA counseling, call
understanding of your skills, talents, and interests. For more information
(l-888-442-4551) or TDD at l-800-829-4833.

Items not mentioned
NOTE: The numbers on the instructions match the item numbers on the application.

are self-explanatory'

and all mail that we've sent to you'
ITEM 3. your vA FILE NUMBER is the number that appears on your VA benefit checks
on whose account you are receiving benefits' Your
Generally, your vA FILE NUMBER is the social securiry number of th" indinidual
SUfplX (iétter or 2-digit number) indicates your relationship to the quali$ing individual'
qualiff for Survivors' and Dependents' Educational Assistance (DEA), you must be either
disabled as a result of a
( I ) The ,pour. oi child of a veteran who is permanently and totally

ITEM

17. To

service-connected disabilitY'
as missing in action,
(2)'captured
The spouse or child of an individual on active duty who has been listed
in
line of duty by hostile
interned
or
detained
forcibly
in line of duty by hostile force,
or pow€r for more
govemment
foreign
by
duty
of
in
line
foice, or forcibly ¿etaineá or interned

'

than 90 daYs.

or who
(3) The surviving spouse or child of a veteran who died of a service-connected disability
nature.
in
total
and
permanent
rated
was
dies while a service-connected disability
that the
(a) The spouse or child of an individual on active duty for which the evidence shows
has a
treatment;
or
services
care
medical
individual is hospitalized for receiving outpatient
active
the
in
duty
of
line
the
in
or
aggravated
total disability pårmanent in nature incurred
released
military, naval,or air service; and the serviceperson is likely to be discharged or
from such service for such disability'
who account benefìts are claimed is no
be terminated in the event that VA determines that the individual on
as captured, missing in action, or forcibly detained'
longer totally disabled or vA is notified that the individual is no longer listed
aftei September 10, 2001, died in the line of duty while
To qualiff for the Fry Scholarship, you must be the child of an individual who

Eligibility for DEA will

serving on active duty as a member of the Armed Forces'

ITEM 21. Select the benefit under which you

education or training
are applying for a change in program or place of training. Types of

programs are self-explanatory, except for the following -

local, or federal agency that is required by law to practice an
"Licensing or cerlification Test.,' A licensing test is a test offered by a state,
individual's qualihcations in a specific occupation'
occupation. A certification test is a test designed to provide affirmation of an
,,National Admission Exam or National Exam for ciedit." Individuals eligible to receive benefits under the Survivors' and Dependents'
for admission to or credit at institutions of higher
Educational Assistance program may be reimbursed for the cost of approved tests
learning,
,,correspondence.,,

Assistance program may

Educational
spouses and surviving spouses eligible for the survivors' and Dependents'
after
quarterly
made
are
courses
foriorrespondence
training. P-ayments
receive benefits fo¡.
courses, please visit our
coffespondence
"o.r.rpondence
on
information
more
For
compläted.
VA receives a certifïcation showing the number of lessons

only

website at www.eibill.va.eov'

Page 3

HOW TO FILE YOUR CLAIM
Be sure to do the following:

(A) If you have selected

a school

or training establishment:

region of that school's physical address'
Step l: Mail the cornpleted form to tlg Vô Regional Processingoffice for the
Ottlces.
Processing
Regional
VA
these
of
addresses
See below for the
that You have applied for VA
Step 2: Tell the veterans certifoing official at your school or.training.establishment
Enrollment
Form22-1999,
VA
using
education benefits. Ask him or her to sena yoúr àniollment informaiion

Certification, or its electrotlic version.
concerning your eligibilify for education
Step 3: Wait for VA to process your application and notify you of its decision
benefits.

(B) If you have not selected a school or training establishment:
region of your home address' See
Step l: Mail the cornpleted form to the VA Regional Processing Office for the
Offices.
Processittg
Regional
VA
these
of
addresses
belàw for the
concerning your eligibility for education
Step 2: Wait for VA to process your application and notify you of its decision
benefits.

Central Region:

Eastern Region:
VA Regional OffÏce
P. O. Box 4616

VA Regional OffÏce
P. O. Box 66830

St. Louis,

tl'.ffqln NV ln.^fi-4616

SERVES'fTIE

SDRVES 1'¡-IE FOLLOWING S]'ATES

CT
MD
NY
VT

DE

DC

MA

NH

NJ

CO
KS

OH

PA

RI

MO

Foreion Schools

SD

VA

ME

NV

OK

LA
OR

TX

UT

WA

HI

IL

IN

MI

MN
ND

NE

WI

P. O. Box 100022
Decatur, GA 30031-7022
SDIìVES TIIE FOLLOWING STA'I'ES

SERVES THE FOLLOWING STATES

AZ

IA

KY
MT
TN

VA Regional Office

lllrrclzncaa |-lk 7¿¿O?--ßßR8
AR
ID

é3!éú-é010-

Southern Region:

Western Region:
VA Regional Office
P. O. Box 8888

AK

Mo

FC ILLOWINC STATE

CA
NM

Philiooines
GUAM

AL
NC

FL

GA

PR

SC

APO/FPO AA

MS
US Virgin

lslands

APO/FPO AP
about our work-study program, call VA
MORE HELP - If you need more help completing this application or you want information
at l-800-829-4833. You can also get more
toll-free
toll-free at l-ggg-GI-BILL-l (l-ggg -++z-+sst¡.Iiyou aietrearing impaired, callus
infonnation about education assistance frorn our education Internet site at www'eibill.va'gov'
the Privacy Act of 1974 or Title 38'
pRlvAcy ACT NoÏcE: vA will not disclose information collected on this form to any source other than what has been authorized under
information to
allows vA to send educational forms or letters with a veteran's identlfy¡ng
Employment Records - vA, published in the Federal Register. An example of routine use
necessary from the
of claims forms or (2) for vA to obta¡n further information as may be
the veteran,s school or train¡ng establishment to (1) assist the veteran ¡n rhe completion
obligation to respond is required to obtain or reta¡n
process
veteran,s education cla¡m or to mon¡tor his or her progress during train¡ng. Your
schoor for vA to properry

the

benefits cannot be
determine the maximum benefits under the law Payment of education
education benefìts. The requested information is cons¡dered rerevant and necessary to

submitted is subiect to verifìcat¡on thfough computer matching programs with other agencies.
for this
benefits (38 u.s.c. 3513). Title 38, united states code, allows us to ask
RESPONDENT BURDEN: We need this ¡nformalion to determine your eligibitity for education
or sponsor a
instruct¡ons, f¡nd the ¡nformat¡on, and complete this form vA cannot conduct
information. we est¡mate that you will need an average of 1 5 m¡nutes to rev¡ew the
page at www.wh¡tehouse.qoviomb/librarv/oMBlNV.VA.EPA html#VA. lf desired, you can call 1'888'G|-BILL-1
control numbers can be located on the OMB lnternet
about this informalion collection'
(1 -8g8-442-4SS1) to get information on where to send comments or suggestions

Page 4