Form 21-674 Request for Approval of School Attendance

Request for Approval of School Attendance (VA Form 21-674 and VA Form 21-674c), School Attendance Report (VA Form 21-674b)

VA Form 21-674 (8-6-14)

Request for Approval of School Attendance (VA Form 21-674 and VA Form 21-674c) School Attendance Report (VA Form 21-674b)

OMB: 2900-0049

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OMB Approved No. 2900-0049
Respondent Burden: 15 minutes
Expiration Date: XXXX

1. ADDRESS OF VA OFFICE

REQUEST FOR APPROVAL OF SCHOOL ATTENDANCE
IMPORTANT - Be sure to read the Instructions on the reverse of Copy 1 before completing this form. The form should be completed in duplicate and signed in Part III.
PART I - TO BE COMPLETED BY CLAIMANT (Also sign certification in Part III)

2A. FIRST NAME-MIDDLE INITIAL-LAST NAME OF VETERAN (Type or Print) 2B. E-Mail ADDRESS OF VETERAN (If
applicable)

3. VA FILE NUMBER

C/CSS
4A. FIRST NAME-MIDDLE INITIAL-LAST NAME OF STUDENT (Veteran's child attending school) (Type or print)
5A. DATE OF BIRTH

4B. STUDENT'S SOCIAL SECURITY NUMBER

5B. HAS STUDENT EVER MARRIED?
YES

NO

6. ADDRESS OF STUDENT (Number and street or rural route, city

or P.O., State and Zip Code)

5C. DATE OF MARRIAGE

(If "Yes," complete Item 5C)
7A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID BY
VA DEPENDENTS EDUCATIONAL ASSISTANCE (DEA), THE FEDERAL EMPLOYEE'S
COMPENSATION ACT OR ANY OTHER AGENCY OR PROGRAM OF THE UNITED STATES
GOVERNMENT?
YES

NO

(If "Yes," complete Items 7B and 7C. If "No," skip to Item 8A)

7B. AGENCY NAME

7C. DATE PAYMENTS BEGAN (Month, day, year)

8A. NAME AND ADDRESS OF SCHOOL FOR WHICH APPROVAL IS REQUESTED

8B. NAME OR TYPE OF COURSE OF EDUCATION OR TRAINING

9A. OFFICIAL BEGINNING DATE OF REGULAR TERM OR
COURSE (Month, day, year)
10A. IS STUDENT ENROLLED IN A FULLTIME HIGH SCHOOL
OR COLLEGE COURSE?
YES
NO

9B. DATE STUDENT STARTED OR EXPECTS TO START
COURSE (Month, day, year)

10B. SUBJECT FOR WHICH STUDENT IS ENROLLED
(If other than full-time high school or college course)

9C. EXPECTED DATE OF GRADUATION
(Month, day, year)
10D. HOURS
PER WEEK

10C. NUMBER OF
SESSIONS PER WEEK

(If "No," complete Items
10B, 10C and 10D)
11A. WAS STUDENT ATTENDING ANY SCHOOL AT END OF
LAST SCHOOL TERM?

11B. NAME AND ADDRESS OF SCHOOL ATTENDED LAST TERM

NO (If "Yes," complete Items 11B thru 11F)

YES

11C. NO. OF SESSIONS
PER WEEK

11D. HOURS PER WEEK

11E. BEGINNING DATE OF LAST TERM

11F. ENDING DATE OF LAST TERM

PART II - STUDENT'S INCOME AND NET WORTH (See instructions on reverse for when required)
12. REPORT OF INCOME BY CALENDAR YEAR (IMPORTANT - Do NOT report VA benefits)
A. SOURCE

B. RECEIVED

(REPORT FOR YEAR IN WHICH SCHOOL
TERM BEGINS-SEE ITEM 9 ABOVE)

C. EXPECTED

(Report for year following
that shown in Column B)

EARNINGS FROM
ALL EMPLOYMENT

13. VALUE OF ESTATE
A. SAVINGS

(Including cash)

$

B. SECURITIES, BONDS,
ETC.

ANNUAL SOCIAL
SECURITY

C. REAL ESTATE

OTHER
ANNUITIES

D. ALL OTHER ASSETS

(Not your home)

ALL OTHER INCOME

E. TOTAL OF ABOVE

(Interest, dividends, etc.)

$

14. REMARKS

PART III - CERTIFICATION AND AGREEMENT TO BE SIGNED BY CLAIMANT
NOTE: This part will be completed by the student only if he or she has attained majority and is claiming benefits in his or her own right. Otherwise, the veteran, surviving
spouse, guardian or custodian will sign and also enter his or her relationship to the student.
Receipt by the student of VA Dependents Educational Assistance (DEA), the Federal Employee's Compensation Act, or benefit from another Federal Agency (U.S. Service
Academy, U.S. Merchant Marine Academy, Bureau of Indian Affairs, etc.) with additional compensation payments based on the student's school attendance is considered a
duplication of benefits and is prohibited.
I CERTIFY THAT the information given above is true and correct to the best of my knowledge and belief and request approval of the course of education or training shown above.

I AGREE to notify the Department of Veterans Affairs immediately of any changes in this course of education, transfer to another school, discontinuance of school
attendance, receipt of Dependents Educational Assistance, or marriage prior to completion of the course. I understand that continued entitlement to school attendance may be
based on information I have furnished on this form. Any benefits allowed due to this certification will be discontinued if the student marries, receives VA Dependents
Education Assistance (DEA) benefits, leaves school, or passes away.

15A. SIGNATURE

15B. DAYTIME PHONE NO.
(Include Area Code)

15C. EVENING PHONE NO.
(Include Area Code)

16. RELATIONSHIP TO STUDENT

17. DATE

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false.
VA FORM
XXXX

21-674

EXISTING STOCKS OF VA FORM 21-674, FEB 2012,
WILL BE USED.

INSTRUCTIONS
NOTE: Read the instructions carefully before completing this form.
How do I complete VA Form 21-674?
VA Form 21-674 should be completed by the person receiving or claiming benefits for a veteran's child who is at least
18 but under 23 and attending school. The veteran's child should complete the form only if he or she has reached the
age of majority and is or will be entitled to receive direct payment of VA benefits. NOTE: The age of majority is
determined by State law; it is age 18 in most states.
Print all answers clearly. For additional space, attach a separate sheet, indicating the item number to which the answers
apply. Make sure to write the veteran's name and VA claim number on any attachments to this form.
Submit the original copy (VA File Copy 1) of the completed form to the VA office shown in Item 1. If no address is
shown, mail or take it to the nearest VA regional office. Keep Claimant's Copy 2 for your own records and use the
reverse, School Attendance Report, to report to VA any change in the child's status, such as termination of school
attendance or marriage.
PART I
All claimants must complete this part. Answer "Yes" to Item 7A only if Federal Employee's Compensation, VA
Dependents Educational Assistance (DEA), or another Federal Agency (U.S. Service Academy, U.S. Merchant Marine
Academy, Bureau of Indian Affairs, etc.) is paying the student's tuition. Do not answer "Yes" simply because Social
Security benefits have been awarded based on the student's continuing school attendance.
PART II
Complete this part only if the benefit being claimed or received is disability pension or death pension. Each income
block must be completed. If you do not receive income from a particular source, write "0" or "none" in the space
provided. Do not leave the space blank. VA will interpret a blank space as "0" or "None". Report the gross amounts
before you take out deductions for taxes, insurance, etc.
Section 306 or Old Law Pension (entitlement to pension established before January 1, 1979): Complete this part only
if the VA benefit payable will be death pension, and there is no surviving spouse entitled to death pension. Do not
complete if the student is a dependent on a veteran's or surviving spouse's award.
Improved Pension: Complete this part showing the student's income. Educational or vocational rehabilitation expenses
are amounts paid by the student for his or her course of post-secondary education or vocational rehabilitation, including
tuition, fees, and materials. If any of these expenses are paid by the student, the expenses may be deducted from the
earned income of the student. Report the total amount(s) paid and dates of payment in Item 14, "Remarks."
PART III
This part will be completed by the student only if he or she has reached the age of majority and is claiming benefits in
his or her right. Otherwise, the veteran, surviving spouse, guardian or custodian will sign and also enter his or her
relationship to the student in Item 16.
Privacy Act Notice: 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. the
requested information is considered relevant and necessary to determine maximum benefits under the law. Giving us your
and your dependents' SSN account information is mandatory. Applicants are required to provide their SSN and the SSN of
any dependents for whom benefits are claimed under Title 38 U.S.C. 5101(c)(1). 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 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 entitlement to benefits for a veteran's child who is between
age 18 and 23 and attending school (38 U.S.C. 104(a)). 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 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.
VA FORM 21-674, XXXX

OMB Approved No. 2900-0049
Respondent Burden: 15 minutes
Expiration Date: XXXXX

SCHOOL ATTENDANCE REPORT
(Unscheduled Termination or Change)

INSTRUCTIONS: The appropriate items below should be completed and the form returned to the Department of Veterans Affairs if
the student whose enrollment is recorded on the face of this form discontinues the approved course of education or training, receives
VA Dependents' Educational Assistance (DEA) benefits, enters an educational institution entirely supported by the Federal
Government or marries prior to completion of the course.
PART I - NOTICE OF TERMINATION OF SCHOOL ATTENDANCE
1A. DATE SCHOOL ATTENDANCE TERMINATED (Month, day, year)

1B. IS THIS THE OFFICIAL ENDING DATE OF REGULAR TERM FOR SUCH COURSE?
YES (If "Yes," complete Item 2A)
NO

2A. BEGINNING DATE OF THE NEXT REGULAR TERM FOLLOWING
THE DATE STUDENT DISCONTINUED SCHOOL (Month, day, year)

(If "No," complete Item 2B)

2B. OFFICIAL ENDING DATE OF REGULAR TERM (Month, day, year)

3. REASON FOR TERMINATION OF ATTENDANCE
E. OTHER (Please explain)

A. FAILURE TO START COURSE OF TRAINING
B. FAILURE TO RESUME COURSE
C. COMPLETION OF COURSE
D. TRANSFER TO ANOTHER INSTITUTION

(Specify name and address of other institution, if known)

4. REASON FOR TERMINATION DUE TO CHANGE IN STATUS
A. RECEIPT OF VA DEPENDENT'S EDUCATIONAL ASSISTANCE (DEA) BENEFITS
B. RECEIPT OF FEDERAL EMPLOYEES' COMPENSATION ACT (FECA)
C. RECEIPT OF OTHER FEDERAL BENEFITS (Such as U.S. Service Academy, U.S. Merchant Marine Academy,
Bureau of Indian Affairs, Job Corp, etc.)
4D. DATE OTHER FEDERAL BENEFITS BEGAN (Month, day, year)

5A. DATE OF MARRIAGE

PART II - NOTICE THAT STUDENT MARRIED
5C. ADDRESS OF STUDENT (No. and street or rural route, city or P.O., State and ZIP Code)

5B. MARRIED NAME (If female student)

6. REMARKS

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
7. NAME OF SCHOOL
8. DATE

9. SIGNATURE OF CLAIMANT, GUARDIAN OR CUSTODIAN

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statements or evidence of a material fact,
knowing it to be false.
VA FORM 21-674, XXXX


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