Form VA Form 22-0803 VA Form 22-0803 Application for Reimbursement of Licensing or Certificat

OMB Approved No. 2900-0695
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

APPLICATION FOR REIMBURSEMENT OF LICENSING OR
CERTIFICATION TEST FEES

IMPORTANT: Complete this application to apply for reimbursement of licensing or certification test fees. You must apply separately
for VA education benefits if you have not already done so. You can receive reimbursement of a licensing or certification test fee if you
qualify for VA benefits under one of the following programs:
Montgomery GI Bill - Active Duty Educational Assistance Program (MGIB) (Chapter 30)
Post-Vietnam Era Veterans Educational Assistance Program (VEAP) (Chapter 32)
Post-9/11 GI Bill (Chapter 33)
Survivors' and Dependents' Educational Assistance Program (DEA) (Chapter 35)
Montgomery GI Bill - Selected Reserve Program (MGIB-SR) (Chapter 1606)
Reserve Educational Assistance Program (REAP) (Chapter 1607)
(See the reverse for Information and Instructions for completing this form.)
PART I - IDENTIFICATION INFORMATION

1. NAME OF APPLICANT (First, Middle Initial, Last Name)

2. MAILING ADDRESS OF APPLICANT (Number and street or rural route, city or P. O., State and ZIP Code)

3. VA FILE NUMBER (For chapter 35, enter the veteran's file number.
Be sure to include the suffix indicator. For dependent transfer cases,
enter the file number of the person who transferred entitlement to you)

4. SOCIAL SECURITY NUMBER (If not shown in Item 3)
5. TELEPHONE NUMBER AND HOURS VA CAN REACH YOU (Include
Area Code)

6. VA EDUCATION INFORMATION

A. HAVE YOU PREVIOUSLY APPLIED FOR VA EDUCATION BENEFITS?
YES

NO

(If "Yes," show the specific benefit you previously applied for in Item 6B)
(If "No," you should complete an application for education benefits)

B. WHAT EDUCATION BENEFIT HAVE YOU APPLIED FOR PREVIOUSLY?
C. WHAT EDUCATION BENEFIT ARE YOU APPLYING FOR NOW?
CHAPTER 32
CHAPTER 33
CHAPTER 35
CHAPTER 30

CHAPTER 1606

CHAPTER 1607

PART II - TEST INFORMATION

7. NAME OF TEST (Specify for each test) (If more space is needed use
Item 11 Remarks)

8. COMPLETE NAME AND MAILING ADDRESS OF ORGANIZATION
ISSUING LICENSE OR CERTIFICATION (Specify for each test)

9. DATE TEST TAKEN AND TEST RESULTS (See the Instructions
for this item for information and evidence you must specify or attach
to this application) (If more space is needed use Item 11 Remarks)

10. COST OF TEST (Specify for each test) (If more space is needed use
Item 11 Remarks)

11. REMARKS

I hereby authorize the release of my test information to the Department of Veterans Affairs (VA).
12. SIGNATURE OF APPLICANT

13. DATE SIGNED

IMPORTANT: To apply for reimbursement of a licensing or certification test fee, please return this form to the VA office which
handles your area. See the addresses on the reverse of this form. Include a copy of your test results.
VA FORM
XXX XXXX

22-0803

SUPERSEDES VA FORM 22-0803, JAN 2014,
WHICH WILL NOT BE USED.

INFORMATION

(The items that are considered self-explanatory are not included in these instructions.)
ITEM 3. If you (or the veteran or serviceperson) were previously assigned an 8-digit file number, enter this number.
ITEM 6. If you have not previously applied for VA education benefits, go to www.benefits.va.gov/gibill/, and click on "Apply
for Benefits". See the top of this form for the education benefits that permit reimbursement of Licensing or Certification tests.
ITEM 7. Write the complete name of the test.
ITEM 8. Write the complete name and complete mailing address (including ZIP Code) of the organization issuing the license or
certificate (not necessarily the organization that administered the test).
ITEM 9. Show the date you took the test and attach a copy of your test results. (If you do not have any test results but have a
copy of your license or certification and a payment receipt for your test, attach these documents.) Reimbursement of the test fee
can't be paid until this information is received. Provide this information for each test you want to receive reimbursement.
ITEM 10. Enter the cost of each test. (We can't reimburse you for registration fees, preparation guides, processing fees, etc.)
ITEMS 12 and 13. Sign and date the form.
Additional Information: You may provide additional information that you think will help VA process your claim. Attach
additional sheets of paper to this application if necessary. Additional information should be properly labeled (such as: Item 1, if the
additional information supports Item 1 on the form).
MORE HELP: If you need help in completing this application, call VA TOLL-FREE at 1-888-GI-BILL-1 (1-888-442-4551).
If you use the Telecommunications Device for the Deaf (TDD), the Federal Relay number is 711. You can also get education
assistance after normal business hours at our education Internet site: www.benefits.va.gov/gibill/.
HOW TO FILE YOUR CLAIM. Send the completed application to the Regional Processing Office in the region of your home
address. Use the addresses below.

EASTERN REGION
VA Regional Office
PO Box 4616
Buffalo, NY 14240-4616

CT
DE
DC
ME
MD

MA
NH
NJ
NY

PA
RI
VT
VA

CENTRAL REGION
VA Regional Office
PO Box 66830
St. Louis, MO 63166-6830

CO
IL
IN
IA
KS
KY

MI
MN
MO
MT
NE
ND

WESTERN REGION
VA Regional Office
PO Box 8888
Muskogee, OK 74402-8888

AL
AK
AR
AZ
CA
FL
HI

ID
LA
MS
NV
NM
OK
OR

SC
TX
UT
WA
Guam
Philippines

SOUTHERN REGION
VA Regional Office
PO Box 100022
Decatur, GA 30031-7022

GA
NC

PR
US Virgin Islands

OH
SD
TN
WI
WV
WY

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 (i.e., VA sends educational forms or letters with a
veteran's identifying information to the veteran's school or training establishment to (1) assist the veteran in the completion of claims forms or (2)
VA obtains further information as may be necessary from the school for VA to properly process the veteran's education claim or to monitor his or
her progress during training) as 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. Your obligation to respond is required to obtain or retain
benefits (licensing and certification test reimbursement). While you do not have to respond, VA cannot reimburse you any licensing and
certification test fees until we receive this information (38 U.S.C. 3452(b) and 3501(a)). Your responses are confidential (38 U.S.C. 5701).
Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine your eligibility for reimbursement of licensing and certification test fees. We
cannot pay you any education benefits for this reimbursement until we receive this information (38 U.S.C. 5101). We estimate that you will need
an average of 15 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 http://www.reginfo.gov/public/do/PRAMain. If desired, you
can call 1-888-GI-BILL-1 (1-800-442-4551) to get information on where to send comments or suggestions about this form. If you are hearing
impaired, call 1-888-829-4833.
VA FORM 22-0803, XXX XXXX