Form 22-0840 ACCELERATED PAYMENT VERIFICATION OF COMPLETION

In Reply Refer To:

Dear
The law requires that we collect some information about the accelerated payment of $
we sent you on
.
If you don't answer before
of $

, you must return the Accelerated Payment

You must sign and return this form to our office before
the address at the top of this letter or FAX it to
you'll be required to pay back $

. You can mail it to
. If you don't reply,

Sincerely,
Education Officer

OMB 2900-0636
Respondent Burden: 5 Minutes
OMB Control No. 2900-0636
Expiration
Date:
XXX_XXXX
Respondent
Burden:
5 Minutes

ACCELERATED PAYMENT VERIFICATION OF COMPLETION
Reminder: You must sign and return this form. If you don't you'll be required to pay back the full amount of
your accelerated payment.
1A. DID YOU INCREASE OR DECREASE THE
NUMBER OF CREDIT/HOURS PURSUED?
YES

NO (If "Yes," complete Items 1B thru 1D)

2A. DID YOU SUCCESSFULLY COMPLETE THE
COURSE(S)?
YES

1B. SPECIFY INCREASE OR DECREASE 1C. NUMBER OF HOURS
INCREASE
DECREASE
1D. DATE THE CHANGE IN HOURS OCCURRED
2B. DATE YOU LAST ATTENDED

NO (If "No," complete Items 2B thru 2C)

2C. EXPLAIN WHY YOU DIDN'T COMPLETE THE COURSE

VA FORM
XXXX

22-0840

(Continued on Reverse)

3. HOW DID YOU USE YOUR PAYMENT? (Check the box that best describes how you used the majority of your payment. There is no right or wrong answer. This
information is being collected for statistical purposes only)
EDUCATION RELATED ITEMS (TUITION, FEES, BOOKS, SUPPLIES, ETC.)
PERSONAL ITEMS (ROOM, BOARD, LIVING EXPENSES, ETC.)
SAVINGS OR CHECKING ACCOUNT
TRAVEL OR ENTERTAINMENT
LOAN REPAYMENT
OTHER (Please specify)

4. REMARKS

I CERTIFY THAT the information given is true and correct to the best of my knowledge.
5A. SIGNATURE OF STUDENT

5B. DATE SIGNED

PRIVACY ACT NOTICE
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 as identified in the VA system of
records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation Records - VA, and published
in the Federal Register. For example, a routine use that allows VA to send educational forms or letters with an 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 VA to obtain further information as may be necessary from the school for VA to properly process
the individual's education claim. Your obligation to respond is required to obtain or retain education benefits. If you do
not respond, VA must collect the payment made to you under 10 U.S.C 16131a, 16162a, or 38 U.S.C. 3014A. 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 confirm your entitlement to the accelerated payment we issued to you (10 U.S.C. 16131a,
16162a, 38 U.S.C. 3014A). Title 38, United States Code, allows us to ask for this information. We estimate that you will
need an average of 5 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 1-888-GI-BILL-1 (1-888-442-4551) to get
information on where to send comments or suggestions about this form.
VA FORM 22-0840, XXXX