Form 28-1917 Monthly Statement of Wages Paid to Trainee (Chapter 31,

OMB Approved No. 2900-0368
Respondent Burden: 30 minutes
Expiration Date: XXXX

MONTHLY STATEMENT OF WAGES PAID TO TRAINEE
(Chapter 31, Title 38, U.S.C.)
INSTRUCTIONS - This statement must be submitted by employer-trainer to the Department of Veterans Affairs not later than the
10th day of the month immediately following the month for which wages were paid. EXAMPLE: Wage statement for January due
not later than February 10, etc. Prepare the form in duplicate, send the original to the Department of Veterans Affairs, and retain
the copy. (See reverse for Privacy Act Information)
1. NAME AND ADDRESS OF VA OFFICE

VA REGIONAL OFFICE

2. FIRST NAME-MIDDLE NAME-LAST NAME OF VETERAN (Type or print)

3. FILE NO.

C4A. TOTAL WAGES, COMPENSATION PAID

NOTE - Report in Item 4A the total wage, compensation or other income paid to the veteran, whether
directly or indirectly. This includes a reasonable value of all items for family living, such as food, fuel,
and shelter furnished by the employer-trainer.

4B. FOR MONTH OF

NOTE - If this is the first time this statement is being completed, please show the monthly rate of pay for both the trainee and trained worker in Items 5A and 5B and
check the box for "start of training" in Item 6. If this is not the first statement and there has been a change in trainee or trained worker monthly rate of pay since the last
statement was submitted, complete Items 5A and 5B and show reason for change in Item 6. In the case of no change in rate of pay since last submission, you do not
have to complete Items 5A, 5B and 6.
5A. TRAINED WORKER MONTHLY RATE OF PAY
(Standard workweek exclusive of overtime)
STANDARD
RATE OF PAY
WORKWEEK (Hours)

$

5B. TRAINEE MONTHLY RATE OF PAY
(Standard workweek exclusive of overtime)
STANDARD
RATE OF PAY
WORKWEEK (Hours)

RATE (Check one)

PER
HOUR

PER
WEEK

PER MONTH
(4-1/3 WEEKS)

RATE (Check one)

PER
HOUR

$

PER
WEEK

PER MONTH
(4-1/3 WEEKS)

6. IF ENTRIES ARE MADE IN 5A AND 5B, INDICATE REASON FOR THE ENTRIES BELOW (Check appropriate box)
START OF TRAINING

INCREASE IN WAGE RATE

OTHER (Specify)

7. REMARKS

CERTIFICATION: I HEREBY CERTIFY THAT the information above is correct.
8. SIGNATURE AND TITLE OF CERTIFYING OFFICIAL OF TRAINING ESTABLISHMENT

9. DATE

10. NAME AND ADDRESS OF TRAINING ESTABLISHMENT

VA FORM
XXXX

28-1917

EXISTING STOCK OF VA FORM 28-1917, DEC 2011,
WILL BE USED.

(See reverse)

PRIVACY ACT INFORMATION
This report is required by law, 38, U.S.C. 1508(c) (1). If you fail to report the requested information, the veteran's VA
vocational rehabilitation benefit may be delayed or issued in an erroneous amount. VA may also be forced to interrupt or
discontinue the trainee's program until the reporting failure is resolved.
The information furnished will not be used for any other purpose and will not be released outside VA unless authorized by the
trainee in writing or unless disclosure is authorized under the Privacy Act of 1974, including the 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. Generally, disclosures under the authority of a routine use will be made to
develop the trainee's claim to vocational rehabilitation benefits under title 38, United States Code.

RESPONDENT BURDEN
We need this information to determine or confirm the proper subsistence allowance rate payable to the trainee. 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send
comments or suggestions about this form.

VA FORM 28-1917, XXXX