Form VA Form 22-8873 VA Form 22-8873 Supplemental Information for Change of Program or Reenro

OMB Approved No. 2900-0358
Respondent Burden: 30 Minutes

SUPPLEMENTAL INFORMATION FOR CHANGE OF PROGRAM OR REENROLLMENT
AFTER UNSATISFACTORY ATTENDANCE, CONDUCT OR PROGRESS
INSTRUCTIONS: Please furnish the information requested in Part I (Item 3) or Part II (Item 4) checked below. Disregard any item
not checked. Also attach any related information that you would like to have considered when VA evaluates your claim. If you need
more space for continuing your answer to an item, use the back of this form. Place your additional information in item 5, Remarks.
Alternately, attach a separate sheet of paper with your additional information to this form.
1. FIRST-MIDDLE-LAST NAME OF VETERAN OR ELIGIBLE PERSON

2. VA FILE NUMBER OR SOCIAL SECURITY NUMBER

PART I - CHANGE OF PROGRAM
3. YOU HAVE CHANGED YOUR EDUCATIONAL OBJECTIVE (PROGRAM). STATE WHY THIS NEW PROGRAM IS THE RIGHT PROGRAM FOR YOU.

PART II - UNSATISFACTORY ATTENDANCE, CONDUCT OR PROGRESS
4. YOUR PREVIOUS SCHOOL STATED THAT YOUR ATTENDANCE, CONDUCT OR PROGRESS WAS UNSATISFACTORY. IF YOU NEED MORE SPACE
FOR YOUR INFORMATION, USE THE BACK OF THIS FORM OR ATTACH A SEPARATE PIECE OF PAPER.
A. STATE WHY YOU HAD UNSATISFACTORY ATTENDANCE, CONDUCT OR PROGRESS.

B. STATE WHAT STEPS OR PRECAUTIONS YOU HAVE TAKEN TO ENSURE THAT THE UNSATISFACTORY ATTENDANCE, CONDUCT, OR
PROGRESS WILL NOT HAPPEN AGAIN.

C. STATE WHY THIS NEW PROGRAM IS THE RIGHT PROGRAM FOR YOU.

VA FORM
AUG 2009

22-8873

SUPERSEDES VA FORM 22-8873, SEP 2006,
WHICH WILL NOT BE USED.

PART III - OTHER INFORMATION
5. REMARKS

I HEREBY CERTIFY THAT the statements contained herein are true and complete to the best of my knowledge and belief.
6. SIGNATURE OF APPLICANT (Do NOT print)
7. DATE

IMPORTANT

If you have already enrolled in an institutional program (college, university, technical school, etc.), you should complete
this form and give it to the Veterans Affairs office at your school. Your school will complete VA Form 22-1999,
Enrollment Certification (if not previously completed) and send all this information to the appropriate VA Office. If you
have not already enrolled in an institutional program, you should complete and return this form to the VA office that sent
it to you.

PRIVACY ACT INFORMATION: 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 1.576 for routine uses identified in the VA system of records, 58VA21/22/28,
Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. An example of
a routine use allows the VA to send educational forms or letters with a individual’s identifying information to the individual’s school or training
establishment to (1) assist the individual in the completion of claims forms or (2) for the VA to obtain further information as may be necessary from
the school for the VA to properly process the individual’s education claim or to monitor his or her progress during training. Your obligation to
respond is required to obtain or retain benefits. 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 enacted before January 1, 1975, and still in effect. The requested information is considered relevant and
necessary to determine the maximum benefits under the law. While you do not have to respond, VA cannot process your claim for education
assistance unless the information is furnished as required by existing law (38 U.S.C. 3471). The responses you submit are considered confidential
(38 U.S.C. 5701). 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 your eligibility for additional educational benefits for a change of program or
reenrollment after unsatisfactory attendance, conduct or progress. (38 U.S.C. sections 3474, 3524 and 3691). Title 38, United States Code, allows us
to ask for this information. We estimate that you will need an average of 30 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.