Form FL21-863 Request for Information to Make Direct Payment to Child

DEPARTMENT OF VETERANS AFFAIRS

.

In Reply Refer To:

based on

You have been receiving VA benefits for
school attendance beyond age 18.
Our records show that this student will reach age of majority in
and, thereafter, will be entitled to receive direct payment.

VA payments may be continued up to the student's 23rd birthday, but will be terminated before then if the
student marries, completes the course of study, or withdraws from school.
To avoid any delay in future checks, the student must furnish the information requested below. Answer
Items 1A through 7, and return this letter to this office as soon as possible. If you have any questions, call
1-800-827-1000 (Hearing Impaired TDD line 1-800-829-4833).
Sincerely yours,
OMB Control No. 2900-0215
Respondent Burden: 10 Mins.
Expiration Date: xxxx
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., civil or criminal law enforcement,
congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the
United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status,
and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational
Rehabilitation and Employment Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain or
retain benefits. Information that you furnish may be utilized in computer matching programs with other Federal or State agencies for the
purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your
participation in any benefits program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: We need this information to determine continued eligibility for death benefits and entitlement to direct payment
(38 U.S.C. 1313 and 1542). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of
10 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 1-800-827-1000 to get information on where to send comments or suggestions about this form.
1A. STUDENT'S ADDRESS (For check mailing purposes)

2A. IS STUDENT ATTENDING SCHOOL?
YES (If "Yes," complete Items 2B and 2C)
NO (If "No," complete Items 3 and 4)

TELEPHONE NUMBER(S) (Include Area Code)
1B. DAYTIME
1C. NIGHTTIME
2B. NAME AND ADDRESS OF SCHOOL

2C. DATE OF GRADUATION

Anticipated date of graduation or
completion of course of study)
3. DATE SCHOOL ATTENDANCE TERMINATED (Mo., day, yr.)

4. REASON FOR TERMINATION OF ATTENDANCE

5A. IS STUDENT MARRIED? 5B. DATE OF MARRIAGE (Mo., day, year) 5C. PLACE OF MARRIAGE (City, State or Country)
YES
6. SIGNATURE

NO
7. DATE
FL 21-863, xxxx(R)