VA Form 28-8739a Protection of Privacy Information Statement

PROTECTION OF PRIVACY INFORMATION STATEMENT
(For Use by Counselees and Rehabilitation Program Participants)
I have been informed and understand that the information requested in this and any later interviews is requested
under the authorization of Title 38, United States Code of Federal Regulations 1.576, Veterans Benefits. This
information is needed to assist in vocational and educational planning, to authorize my receipt of rehabilitation
services, to develop a record of my vocational progress, and to assure I obtain the best results from my
rehabilitation program. I understand that the information I provide will not be used for any other purpose and
that my responses may be disclosed outside VA only if the disclosure is authorized under the Privacy Act of
1974, including the routine uses identified in the VA system of records, 58VA21/22, Compensation, Pension,
Education and Rehabilitation Records - VA, and published in the Federal Register. Generally, disclosures
under the authority of a routine use will be made to develop my claim for vocational rehabilitation benefits
under Title 38, United States Code.
My giving the requested information is voluntary. I understand that the following results might occur if I do
not give this information:
(1) I may not receive the maximum benefit either from counseling or from my education or rehabilitation
program.
(2) If certain information is required before I may enter a VA program, my failure to give the information
may result in my not receiving the education or rehabilitation benefit for which I have applied.
(3) If I am in a program in which information on my progress is required, my failure to give this
information may result in my not receiving further benefits or services.
My failure to give this information will not have a negative effect on any other benefit to which I may be
entitled.
I HEREBY CERTIFY THAT the information I have given is true and correct to the best of my knowledge and
belief.

(Veteran’s Signature)

VA FORM
AUG 2005

28-8739a

(Date Signed)

EXISTING STOCK OF VA FORM 28-8739a, AUG 1989,
WILL BE USED.