Form VA Form 22-5490 VA Form 22-5490 Dependents' Application For VA Education Benefits

OMB Approved No. 2900-0098
Respondent Burden: 45 minutes
Expiration Date: XX/XX/XXXX

DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(Under Provisions of chapters 33 and 35, of title 38,U.S.C.)

INTERNET VERSION AVAILABLE - You may complete and submit your application online at: www.benefits.va.gov/gibill.

PART I - APPLICANT INFORMATION
1. SOCIAL SECURITY NUMBER

2. SEX OF APPLICANT
MALE

3. DATE OF BIRTH

FEMALE

4. NAME (First name, middle initial, last name)
5. CURRENT MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

6. TELEPHONE NUMBER(S) (Including Area Code)
SECONDARY

PRIMARY
7. E-MAIL ADDRESS

8. DIRECT DEPOSIT (Attach a voided personal check or provide the following information. See instructions for additional information.)
ROUTING OR TRANSIT NUMBER

ACCOUNT NUMBER

ACCOUNT TYPE
CHECKING

SAVINGS

9. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
A. NAME

C. TELEPHONE NUMBER (Include Area Code)

B. ADDRESS

PART II - QUALIFYING INDIVIDUAL INFORMATION
10. NAME OF QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (First name, middle initial, last name)
11. SOCIAL SECURITY NUMBER OR VA FILE NUMBER

12. BRANCH OF SERVICE

14. DATE OF DEATH OR DATE LISTED AS
MISSING IN ACTION OR P.O.W.

13. DATE OF BIRTH

15. IS QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON ACTIVE
DUTY?
YES

NO

16. DO YOU (APPLICANT) OR THE QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
YES

NO

PART III - BENEFIT AND TYPE OF EDUCATION OR TRAINING
17A. DATE YOU WILL BEGIN SCHOOL OR TRAINING
MONTH

DAY

VA DATE STAMP
(For VA Use Only)

YEAR

17B. TYPE OF EDUCATION OR TRAINING
COLLEGE OR OTHER SCHOOL
FARM COOPERATIVE
LICENSING OR CERTIFICATION TEST
APPRENTICESHIP OR OTHER ON-THE-JOB TRAINING
NATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDIT
CORRESPONDENCE COURSE (DEA Children not eligible)
FLIGHT TRAINING (Fry Scholarship only)
17C. ARE YOU SEEKING SPECIAL RESTORATIVE TRAINING?
YES
VA FORM
XXX XXXX

NO

22-5490

17D. ARE YOU SEEKING SPECIAL VOCATIONAL TRAINING?
YES

SUPERSEDES VA FORM 22-5490, JUN 2014,
WHICH WILL NOT BE USED.

NO

PAGE 1

SOCIAL SECURITY NUMBER OF APPLICANT
18A. NAME AND ADDRESS OF SCHOOL OR TRAINING FACILITY (Number and street or rural route, city or P.O., State and ZIP Code)

18B. IN WHAT STATE DO YOU ANTICIPATE LIVING WHILE PARTICIPATING IN THIS TRAINING (You must notify us immediately if the state in which you live changes

from the state indicated below)

GIVE TWO-LETTER POSTAL ABBREVIATION CODE
19. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE, IF KNOWN (e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer )

20. WOULD YOU LIKE TO RECEIVE VOCATIONAL AND EDUCATIONAL COUNSELING? (Please see Item 20 in the instruction section for more details about vocational

and educational counseling)
YES

NO

PART IV - BENEFIT ELECTION
IMPORTANT: For help completing this section, please see the attached instructions page or click on the "Summary of VA Education Benefits" link at www.benefits.
va.gov to compare various benefits and eligibility criteria. For general information, visit our website at www.benefits.va.gov/gibill.
21. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL (Check only one)
SPOUSE/SURVIVING SPOUSE

CHILD/STEPCHILD/ADOPTED CHILD

(Please complete only Section I below,
and then proceed to Part V)

(Please complete only Section II below,
and then proceed to Part V)
SECTION I - SPOUSE/SURVIVING SPOUSE

22. IS A DIVORCE OR ANNULMENT PENDING TO THE QUALIFYING INDIVIDUAL?
YES

NO

23. IF YOU ARE THE SURVIVING SPOUSE, HAVE YOU REMARRIED?
YES

NO

(If "Yes," please provide date of remarriage)

MONTH

DAY

YEAR

24. PLEASE SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW

IMPORTANT: If you are eligible for Chapter 35 Survivors' and Dependents' Educational Assistance Program (DEA) and eligible for Chapter 33
Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship (Fry Scholarship), you must relinquish entitlement to the benefit that you
are not applying for (even if entitlement arises from separate events). You cannot retain eligibility for both programs simultaneously. By checking
the box below, you agree and understand that you are making an irrevocable election to receive the selected benefit and your election may not be
changed. PLEASE CAREFULLY READ THE INFORMATION AND INSTRUCTIONS PAGE BEFORE MAKING A SELECTION.
A. I AM APPLYING FOR CHAPTER 35 - DEA

By checking this box I acknowledge that I understand this
election is irrevocable and may not be changed.

B. I AM APPLYING FOR CHAPTER 33 - FRY SCHOLARSHIP

By checking this box I acknowledge that I understand this
election is irrevocable and may not be changed.

SECTION II - CHILD/STEPCHILD/ADOPTED CHILD
25. PLEASE SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW

IMPORTANT: If you are eligible for Chapter 35 Survivors' and Dependents' Educational Assistance Program (DEA) and eligible for Chapter 33
Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship (Fry Scholarship), you must relinquish entitlement to the benefit that you
are not applying for (but only with regards to the entitlement arising from the same events). You cannot retain eligibility for both programs based
on the same event. By checking the box below, you agree and understand that you are making an irrevocable election to receive the selected benefit and
your election may not be changed. PLEASE CAREFULLY READ THE INFORMATION AND INSTRUCTIONS PAGE BEFORE MAKING A
SELECTION.
A. I AM APPLYING FOR CHAPTER 35 - DEA

By checking this box I acknowledge that I understand this
election is irrevocable and may not be changed.

B. I AM APPLYING FOR CHAPTER 33 - FRY SCHOLARSHIP

By checking this box I acknowledge that I understand this
election is irrevocable and may not be changed.

IMPORTANT: While receiving DEA or FRY Scholarship benefits you may not receive payments of Dependency and Indemnity Compensation (DIC)
or Pension and you may not be claimed as a dependent in a Compensation claim. CAREFULLY READ THE INSTRUCTIONS BEFORE COMPLETING
THE ELECTION BLOCK BELOW. YOU ARE STRONGLY ENCOURAGED TO DISCUSS YOUR ELECTION WITH A VA COUNSELOR.

26. I CERTIFY THAT I UNDERSTAND THE EFFECTS THAT THIS ELECTION TO RECEIVE DEA OR FRY SCHOLARSHIP BENEFITS WILL HAVE ON MY ELIGIBILITY TO
RECEIVE DIC, AND I ELECT TO RECEIVE SUCH EDUCATION BENEFITS ON THE FOLLOWING DATE:
MONTH
YEAR
DAY
YES

NO

(If "Yes," please provide date of election)

VA FORM 22-5490, XXX XXXX

PAGE 2

SOCIAL SECURITY NUMBER OF APPLICANT

PART V - APPLICATION HISTORY
27. PRIOR TO THIS APPLICATION, HAVE YOU EVER APPLIED FOR OR RECEIVED ANY OF THE FOLLOWING VA BENEFITS? (Check all appropriate boxes)
A.

DISABILITY COMPENSATION OR PENSION

B.

DEPENDENTS' INDEMNITY COMPENSATION (DIC)

C.

VOCATIONAL REHABILITATION BENEFITS (Chapter 31)

D.

VETERANS EDUCATION ASSISTANCE BASED ON YOUR OWN SERVICE SPECIFY BENEFIT(S):

E.

VETERANS EDUCATION ASSISTANCE BASED ON SOMEONE ELSE'S SERVICE
SPECIFY BENEFIT(S) BY CHECKING APPLICABLE BOX BELOW AND COMPLETE ITEMS 28 AND 29
CHAPTER 35 - SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE PROGRAM (DEA)
CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY SERGEANT DAVID FRY SCHOLARSHIP
TRANSFERRED ENTITLEMENT

F.

NONE

G.

OTHER (Specify benefit(s)

IMPORTANT: Complete Items 28 and 29 only if you checked block "E" in Item 27

28. NAME OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS (First, Middle, Last)

29. SOCIAL SECURITY NUMBER OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS

PART VI - APPLICANT'S MILITARY SERVICE INFORMATION

(Note: Chapter 35 benefits are not payable while an eligible person is on active duty)

30. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES? (If "No," skip to Part VII)
YES

NO

31. INFORMATION ABOUT YOUR PERIOD(S) OF ACTIVE DUTY
C. BRANCH OF SERVICE OR
RESERVE OR GUARD
COMPONENT

B. DATE SEPARATED FROM
ACTIVE DUTY

A. DATE ENTERED ACTIVE DUTY

D. CHARACTER OF DISCHARGE

PART VII - EDUCATION, TRAINING, AND EMPLOYMENT
SECTION I - EDUCATION & TRAINING
32. CHECK THE APPROPRIATE BOX AND ENTER THE DATE IN ITEM 33

33. DATE

GRADUATED FROM HIGH SCHOOL

DISCONTINUED HIGH SCHOOL

EXPECT TO GRADUATE FROM HIGH SCHOOL

AWARDED GED

NEVER ATTENDED HIGH SCHOOL

34A.
TYPE OF
SCHOOL

34B. NAME AND
LOCATION OF SCHOOL
(City and State)

34C. DATES OF TRAINING
FROM

TO

34D. NUMBER OF
SEMESTER,
QUARTER, OR CLOCK
HOURS COMPLETED

34E. DEGREE,
DIPLOMA, OR
CERTIFICATE
RECEIVED

34F. MAJOR FIELD OR
COURSE OF STUDY

HIGH SCHOOL
COLLEGE
VOCATIONAL
OR TRADE
OTHER

(Specify)

VA FORM 22-5490, XXX XXXX

PAGE 3

SOCIAL SECURITY NUMBER OF APPLICANT
SECTION II - EMPLOYMENT
35. CURRENT AND PAST EMPLOYMENT
A. EMPLOYER

B. JOB TITLE

C. NUMBER OF MONTHS
EMPLOYED

D. LICENSE OR RATING

NOTE: Complete Item 36 only if you are a civilian employee of the U.S. Government.
36A. DO YOU EXPECT TO RECEIVE FUNDS FROM YOUR AGENCY OR
DEPARTMENT FOR THE SAME COURSES FOR WHICH YOU EXPECT TO
RECEIVE VA EDUCATIONAL ASSISTANCE? (If "Yes," complete Item 36B)
YES

36B. SOURCE OF EDUCATIONAL ASSISTANCE FROM GOVERNMENT
EMPLOYMENT

NO

PART VIII - REMARKS, REMINDERS AND VA EDUCATION BENEFITS PAMPHLET
SECTION I - REMARKS
37. REMARKS (If more space is needed, please attach a separate sheet of paper. Be sure to include name and social security number on each sheet)

SECTION II - REMINDERS

DID YOU REMEMBER TO:

WRITE YOUR SOCIAL SECURITY NUMBER ON EACH PAGE
WRITE YOUR COMPLETE MAILING ADDRESS
ATTACH SUPPORTING DOCUMENTS (e.g., birth certificate, marriage license, DD214, etc.)
SECTION III - VA EDUCATION BENEFITS PAMPHLET
38. THE MOST CURRENT INFORMATION ON VA EDUCATION BENEFITS IS AVAILABLE ONLINE AT www.benefits.va.gov/gibill. IF YOU WOULD LIKE A COPY OF THE
VA EDUCATION BENEFITS PAMPHLET PLEASE CHECK THE BOX.

PART IX - CERTIFICATION AND SIGNATURE OF APPLICANT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.
39A. SIGNATURE OF APPLICANT (DO NOT PRINT)

39B. DATE SIGNED

SIGN HERE
IN INK

PENALTY: Willfully false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the forfeiture of these or other
benefits and in criminal penalties.
VA FORM 22-5490, XXX XXXX

PAGE 4

(Please detach at perforation and retain this information for future reference)
INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(VA FORM 22-5490)
Do not use this form to apply for Veterans' education assistance based on your own service (chapters 30, 32, 33, 1606, or 1607) or
vocational rehabilitation benefits (chapter 31). To apply for veterans' education assistance based on your own service, use VA Form
22-1990. To apply for vocational rehabilitation benefits, use VA Form 28-1900.
INTERNET VERSION AVAILABLE - You may complete and submit this application on-line at www.benefits.va.gov/gibill. Click on "GI
Bill: Apply for Benefits."
NOTE: The number on the instructions match the item numbers on this application. Items not mentioned are self-explanatory.
ITEM 8. The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called
direct deposit. Please attach a voided personal check or deposit slip or provide the information requested below to enroll in direct
deposit. If you do not have a bank account, you must receive your payment through Direct Express Debit MasterCard. To request a
Direct Express Debit MasterCard, you must apply at www.usdirectexpress.com or by telephone at 1-800-333-1795. If you elect not to
enroll, you must contact representatives handling waiver requests for the Department of Treasury at 1-888-224-2950. They will
address any questions or concerns you may have and encourage your participation in EFT.
ITEM 16. You will not be eligible to receive benefits for any period for which you or the qualifying individual on whose account you are
claiming benefits has an outstanding felony warrant. Any benefits paid to you for such period will result in an overpayment and be
subject to collection.
ITEM 17B. Types of education or training programs are self-explanatory, except for the following:
"Licensing or Certification Test." A licensing test is a test offered by a state, local, or federal agency that is required by law to practice
an occupation. A certification test is a test designed to provide affirmation of an individual's qualifications in a specific occupation.
"National Admission Exam or National Exam for Credit." Individuals eligible to receive benefits under the Survivors' and Dependents'
Educational Assistance program may be reimbursed for the cost of approved tests for admission to or credit at institutions of higher
learning.
"Correspondence." Only spouses and surviving spouses eligible for the Survivors' and Dependents' Educational Assistance program
may receive benefits for correspondence training. Payments for correspondence courses are made quarterly after VA receives a
certification showing the number of lessons completed. For more information on correspondence courses, please visit our website at
www.gibill.va.gov.
"Flight Training." You must already have a private pilot's license. If you are taking an Airline Transport Pilot course, you must have a
valid first-class medical certificate on the date that you enter training. For all other flight courses, you must have a valid second-class
medical certificate on the date that you enter training.
ITEMS 17C and 17D. Any individual eligible under the Survivors' and Dependents' Educational Assistance program may receive
Special Restorative Training or Specialized Vocational Training if a VA counselor determines that a specialized program is needed to
overcome the effects of a physical or mental handicap. To be eligible for receipt of specialized training, the disability must prevent you
from pursuing an educational program. Examples of Special Restorative Training include speech and voice correction, language
retraining, lip reading, and Braille reading and writing. Specialized Vocational Training consists of specialized courses leading to a
suitable vocational objective.
ITEM 20. VA VOCATIONAL AND EDUCATIONAL COUNSELING HELP AVAILABLE - VA offers a wide range of services to assist
you in planning your educational and/or career goals. Services include educational and vocational guidance and testing to develop a
greater understanding of your skills, talents, and interests. For more information on VA counseling, call VA toll-free at 1-888-GIBILL-1
(1-888-442-4551) or if you use the Telecommunications Device for the Deaf (TDD), the Federal Relay number is 711.
ITEM 21. If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where
you and/or your spouse resided at the time of marriage or where you and/or your spouse resided when you filed your claim (or a later
date when you became eligible for benefits) (38 U.S.C. § 103(3)). Additional guidance on when VA recognizes marriages is available at
http://www.va.gov/opa/marriage/.

VA FORM
XXX XXXX

22-5490

SUPERSEDES VA FORM 22-5490, JUN 2014,
WHICH WILL NOT BE USED.

INFORMATION AND INSTRUCTIONS (Continued)
ITEMS 24 and 25. Select the benefit for which you are applying.
To qualify for Survivors' and Dependents' Educational Assistance (DEA) you must be either (1) The spouse or child of a veteran who is permanently and totally disabled as a result of a service-connected disability.
(2) The spouse or child of an individual on active duty who has been listed as missing in action, captured in the line of duty by
hostile force, forcibly detained or interned in the line of duty by hostile force, or forcibly detained or interned in the line of duty by foreign
government or power for more than 90 days.
(3) The surviving spouse or child of a veteran who died of a service-connected disability or who dies while a service-connected
disability was rated permanent and total in nature.
(4) The surviving spouse or child of an individual on active duty for which the evidence shows that the individual is hospitalized
for receiving outpatient medical care services or treatment; has a total disability permanent in nature incurred or aggravated in the line
of duty in the active military, naval, or air service; and the serviceperson is likely to be discharged or released from such service for
such disability.
Eligibility for DEA will be terminated in the event that VA determines that the individual on whose account benefits are claimed
is no longer totally disabled or VA is notified that the individual is no longer listed as captured, missing in action, or forcibly detained.
To qualify for the Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship, you must be the surviving spouse or child of
an individual who died in the line of duty while serving on active duty as a member of the Armed Forces after September 10, 2001.
ITEMS 24 and 25. Irrevocable Election - Your decision to elect one benefit over the other CANNOT be changed once you have
submitted this application. Furthermore, your election will be effective as of the date indicated in Item 39B of this form. In the event that
Item 39B is inadvertently left incomplete, the effective date of the election will, by default, be the date VA receives this application.
However, if either the date in Item 39B of this form or the date VA receives this application is earlier than January 1, 2015, then the
effective date of the election will be the later of either, the date the school training begins (as found in Item 17A of this application) or
January 1, 2015.
ITEM 24A. By selecting this box you are agreeing to the following statement: I understand that if I am also eligible for Fry
Scholarship benefits then I am electing to receive DEA benefits in lieu of any Fry Scholarship benefits for which I am currently eligible
including Fry Scholarship benefits based on the death of the individual listed in Item 10 of this application, as well as, Fry Scholarship
benefits based on the death of any other individuals not identified on this application.
ITEM 24B. By selecting this box you are agreeing to the following statement: I understand that I am electing to receive Fry
Scholarship benefits in lieu of any DEA benefits for which I am currently eligible including DEA benefits based on the death of the
individual listed in Item 10 of this application, based on the death of any other individuals not identified on this application, based on a
spouse who has a total disability permanent in nature resulting from a service-connected disability, or based on any other criteria as
listed in 38 U.S.C. § 3501(a)(1).
IITEM 25A. By selecting this box you are agreeing to the following statement: I understand that if I am also eligible for Fry
Scholarship benefits based on the death of the individual listed in Item 10 of this application then I am electing to receive DEA benefits
in lieu of any Fry Scholarship benefits based on that death. Furthermore, I understand that even after this election I will continue to
retain any current eligibility to Fry Scholarship benefits if the eligibility is based on the death of an individual not listed in Item 10 of this
application.
ITEM 25B. By selecting this box you are agreeing to the following statement: I understand that I am electing to receive Fry
Scholarship benefits in lieu of any DEA benefits for which I am currently eligible based on the death of the individual identified in Item
10. Furthermore, I understand that even after this election I will continue to retain any current eligibility to DEA benefits if the eligibility is
based on the death of an individual not listed in Item 10 of this application, based on a parent who has a total disability permanent in
nature resulting from a service-connected disability, or based on any other criteria as listed in 38 U.S.C. § 3501(a)(1).
ITEM 26. Your election to receive Survivors' and Dependents' Education Assistance (DEA) in lieu of payments of compensation,
pension, and Dependents' Indemnity Compensation (DIC) is final and cannot be changed. This means that payments of compensation,
pension, and Dependents' Indemnity Compensation (DIC) will be terminated upon issuance of a DEA benefit payment. If you are
planning to pursue a program of education for more than 45 months, you should consider deferring receipt of DEA benefits. We strongly
recommend that you discuss your education or training plans with a VA counselor before making a decision. If you decide to elect
benefits under DEA, indicate the date from which you wish your DEA payments to begin.

VA FORM 22-5490, XXX XXXX

HOW TO FILE YOUR CLAIM
You may complete and submit your application online at www.benefits.va.gov/gibill or be sure to do the following:
(A) If you have selected a school or training establishment:
Step 1: Mail the completed application to the VA Regional Processing Office for the region of that school's physical address.
See the last page for addresses of the VA Regional Processing Offices.
Step 2: Tell the veterans certifying official at your school or training establishment that you have applied for VA education
benefits. Ask him or her to submit your enrollment information using VA Form 22-1999, Enrollment Certification, or its electronic
version.
Step 3: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.

(B) If you have not selected a school or training establishment:
Step 1: Mail the completed application to the VA Regional Processing Office for the region of your home address. Check next
page for the post office box address for these offices.
Step 2: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.

ADDITIONAL HELP COMPLETING APPLICATION
If you need additional help completing this application or you want information about our work-study program, call VA tollfree at 1-888-GIBILL-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 more information about education assistance from our education Internet site at
www.benefits.va.gov/gibill.

VA FORM 22-5490, XXX XXXX

Eastern Region:
VA Regional Office
P. O. Box 4616
Buffalo, NY 14240-4616

Southern Region:
VA Regional Office
P. O. Box 100022
Decatur, GA 30031-7022

SERVES THE FOLLOWING STATES

SERVES THE FOLLOWING STATES

CT

DE

DC

ME

MD

MA

NH

NJ

NY

PA

RI

VT

VA

Foreign
Schools

GA

NC

PR

US Virgin
Islands

APO/FPO AA

Western Region:
VA Regional Office
P. O. Box 8888
Muskogee, OK 74402-8888

Central Region:
VA Regional Office
P. O. Box 66830
St. Louis, MO 63166-6830

SERVES THE FOLLOWING STATES

SERVES THE FOLLOWING STATES

AK

AL

AR

AZ

CO

IA

IL

IN

CA

FL

HI

ID

KS

KY

MI

MN

LA

MS

NM

NV

MO

MT

NE

ND

OK

OR

SC

TX

OH

SD

TN

WV

UT

WA

Philippines

Guam

WI

WY

APO/FPO AP

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., awards of benefits) 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 education benefits. Giving us your SSN account information is voluntary.
Refusal to provide your SSN by itself will not result in the denial of benefits. 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 in effect prior to January 1, 1975, and still in effect. The requested
information is considered relevant and necessary to determine the maximum benefits allowable under the law. While you do not have to respond,
VA cannot process your claim for benefits unless the information is furnished as required by existing law (38 U.S.C. 3513). The responses you
submit are considered 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 education benefits (38 U.S.C. 3513). Title 38 U.S.C.
allows us to ask for this information. We estimate that you will need an average of 45 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 (1-888-442-4551) to get information on where to
send comments or suggestions about this form.

VA FORM 22-5490, XXX XXXX