22-8691 Application For Work-study Allowance

OMB Approved No. 2900-0209
Respondent Burden: 15 minutes
Expiration Date: XXXXX

APPLICATION FOR WORK-STUDY ALLOWANCE
PART I - IDENTIFICATION INFORMATION

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

2. MAILING ADDRESS OF APPLICANT (Number, and street or rural route, city or

P.O., State and 9 digit ZIP Code)

3A. VA FILE NUMBER (For chapter 35, enter the veteran's file number.

Be sure to include the suffix indicator. For dependent's transfer of
entitlement cases, enter the file number of the person who transferred
entitlement to you)

3B. SOCIAL SECURITY NUMBER (If not shown in Item 3A)
3D. SEX OF APPLICANT
MALE

3C. DATE OF BIRTH OF APPLICANT (Month, Day, Year)

FEMALE

4B. PLEASE PROVIDE THE HOURS THAT VA CAN REACH YOU
DAYTIME
EVENING

4A. TELEPHONE NUMBER (Include Area Code)

CHAPTER 30 (Montgomery GI Bill - Active Duty)

CHAPTER 33 (Post- 9/11 GI Bill)
CHAPTER 35 (Dependents Educational Assistance)

CHAPTER 31 (Vocational Rehabilitation)

CHAPTER 1606 (Montgomery GI Bill - Selected Reserve)

CHAPTER 32 (Veterans Educational Assistance Program)

CHAPTER 1607 (Reserve Educational Assistance Program)

5. EDUCATION BENEFIT RECEIVING

6A. NAME AND COMPLETE ADDRESS OF SCHOOL

(Month, Day, Year)

entitled to benefits)

PART II - SCHOOL INFORMATION

6B. CURRENT ACADEMIC OR TRAINING PROGRAM

8. NEXT ENROLLMENT PERIOD YOU PLAN TO ATTEND

7. CURRENT ENROLLMENT INFORMATION
A. BEGINNING DATE

TRANSFER OF ENTITLEMENT
PROGRAM (Parent or Spouse

B. ENDING DATE

A. BEGINNING DATE

(Month, Day, Year)

(Month, Day, Year)

B. ENDING DATE

(Month, Day, Year)

PART III - WORK STUDY INFORMATION

9. ADVANCE PAYMENT - DO YOU WANT AN ADVANCE PAYMENT? (See instructions for information on advance payment on reverse under "How Much Can I Earn?")
YES

NO

10. HAVE YOU EVER PARTICIPATED IN THE VA WORK-STUDY
PROGRAM BEFORE? (If "YES," please state where you worked)
YES

11. WORK SITE PREFERENCE (Tell us the school, VA facility or other government

facility where you would prefer to do VA related work. Be specific as many facilities
have the same name or perform the same services in different locations or cities.)

NO

12. WORK EXPERIENCE (Tell us about the jobs you had before,

other than VA work-study jobs. Please be as specific as possible.
If you have no work experience, place "NONE" in this space. If
needed, attach a separate sheet with your work-history)

13. SPECIFY THE DAYS AND HOURS DURING THE WEEK YOU ARE AVAILABLE TO WORK

(X)

DAYS

WHEN AVAILABLE (From & To)

MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
14. QUALIFICATIONS (Tell us about any special qualifications you have based on your education or work experience. Include any experience in information
technology. Also, tell us what kinds of jobs interest you. If needed, attach a separate sheet with this information)

15. SIGNATURE OF APPLICANT (Do not print)

16. DATE SIGNED

PRIVACY ACT INFORMATION: VA will not disclose information collected by this information collection to any source other than what has been authorized by the Privacy Act of 1974 or
Title 38 Code of Federal Regulations 1.576 for routine uses as identified in VA's system of records, 58 VA 21/22/28, Compensation, Pension, Education and Vocational Rehabilitation Records VA as published in the Federal Register at http://www.rms.oit.va.gov/SOR_Records/58VA21_22.asp. An example of a routine use allows VA to send 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) for VA to obtain 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. Your obligation to respond is "required to obtain or retain benefits". We
cannot pay you any work-study benefits until we receive this information (38 U.S.C. 3485). Your responses are confidential (38 U.S.C. 5701). Any information provided by applicants may be
subject to verification through computer matching programs with other agencies.
Respondent Burden: We need this information to determine your eligibility for VA work-study benefits. Title 38 United States Code allows us to ask for this information. We estimate that you
will need an average of 15 minutes to review the instructions, find the information, and complete the 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.htm#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.
VA FORM
EXISTING STOCKS OF VA FORM 22-8691, JUL 2012,
XXXX
WILL NOT BE USED.

22-8691

HOW MUCH CAN I EARN?
Your hourly pay rate will be the greater of:
(1) The Federal minimum wage; or
(2) The minimum wage for the State in which you are
working.
The total number of hours you can work cannot be more
than 25 times the number of weeks in your enrollment
period. If you elect to receive an advance payment, VA will
make your first payment in advance of your work for the
lesser of:
(1) 40 percent of the total amount of the work-study
allowance to be paid under your contract agreement
with VA; or
(2) 50 hours at your hourly pay rate.
You can only receive one advance payment per contract
agreement (original contract agreement and any extension
to that contract agreement).
If you do not elect to receive an advance payment, VA will
pay you for any hours after you work the hours.
Your final payment will be for the lesser of:
(1) 50 hours; or
(2) The number of hours remaining on your contract.

Department of Veterans Affairs

WHO IS ELIGIBLE?
You are eligible if you're training in a college degree,
vocational, or professional program at least three-quarter
time. You can receive a work-study allowance (in addition to
your education benefits) based on the number of hours of
work you perform. A work-study allowance is available under
most educational assistance programs administered by VA.

Official Business
Penalty for Private Use $300

STUDENT WORK-STUDY
ALLOWANCE PROGRAM

Student Work-Study
Allowance Program

WHAT TYPE OF WORK MAY I DO?
You may do the following types of VA-related work:

.
.
.
.
.
.
.

VA paperwork at schools;
VA paperwork at VA offices or facilities;
VA outreach services under VA supervision;
Outreach services as provided by a State approving
agency;
Provide hospital, home-care, or medical treatment
to veterans at VA medical facilities or other approved
facilities (including a State home receiving VA per
diem assistance);
Administrative (office) work at a national cemetery
or a State veteran's cemetery;
Work at Department of Defense facilities related to
education benefits under the Montgomery GI
Bill-Selected Reserve (MGIB-SR) or the Reserve
Educational Assistance Program (REAP).
NOTE: Only claimants receiving MGIB-SR or REAP
benefits can do this type of work.

Veterans Benefits Administration
HOW DO I APPLY?
Complete the form on the other side of this page, and mail it to the
VA Regional Processing Office that handles your education claim. You
can get more information or send us an email via VA's website www.
gibill.va.gov by clicking on "Questions and Answers" and then clicking
on "Ask a Question & Find an Answer." Or you can call us at our tollfree number, 1-888-GIBILL-1(1-888-442-4551). If you use the
Telecommunications Device for the Deaf, the Federal Relay number
is 711.