Veterans Retraining Assistance Program

OMB Control Number XXXX-XXXX, Exp. XX/XX/XXXX.

Veterans Retraining Assistance Program

1. Last Name: ___________________________________________________

2. First Name: ___________________________________________________ MI _________

3. Date of Birth: MM/DD/YYYY

4. Date of this Application: MM/DD/YYYY

DOL ELIGIBILITY DETERMINATION

5. Are you currently employed ________ y/n;

6. Have you been enrolled in a federal or state job training program in the past 180 days? _________ y/n;

Examples include any training funded by: a local career center, a One-Stop Career Center, or any state or local employment office.

The information provided on this application will be used for the purposes of determining your eligibility to receive retraining assistance benefits from the Department of Veterans Affairs. The information may be audited for accuracy. By checking the box below, you agree to the following statement:

□ I swear or affirm that the statements on this application, to the best of my knowledge, are true and correct. I understand that by submitting this application, I am making a statement to the government for the purposes of obtaining federal benefits. Section 1001 of Title 18 of the U.S. Code makes it a criminal offense for any person to knowingly and willfully make false or fraudulent statements to any department or agency of the United States Government. Additionally, I understand that if the information I have provided on this application is found to be false or incorrect, I will be immediately unable to receive benefits under this program, and I may be required to reimburse the Government for any benefits I have already received.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this required to obtain or retain benefit (VOW to Hire Heroes Act of 2011, Pub. L. 112-56 Sec. 211). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employment and Training Administration, 200 Constitution Avenue, N.W., Room S-4209, Washington, DC 20210 and reference the OMB Control Number XXXX-XXXX.