21-674b School Attendance Report

OMB Approved No. 2900-0049
Respondent Burden: 5 minutes
Expiration Date: XXXX

1. VA FILE NUMBER

SCHOOL ATTENDANCE REPORT

C/CSS -

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 5 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.
2. VA OFFICE TO WHICH THIS FORM SHOULD BE RETURNED

3A. FIRST, MIDDLE, LAST NAME OF VETERAN
3B. E-MAIL ADDRESS OF VETERAN (If applicable)
4A. FIRST, MIDDLE, LAST NAME OF STUDENT
4B. SOCIAL SECURITY NUMBER OF STUDENT

INSTRUCTIONS: Complete either Part I or Part II, and return the completed form to the VA office shown in Item 2.
PART I - VERIFICATION OF SCHOOL ATTENDANCE

(To Be Completed By Claimant)

Benefits have been awarded because the student named in Item 4 expects to start a course of training. Complete Part I, and return this form to the VA
office shown in Item 2 within 60 days after the date the student begins the course. If the form is not returned, benefits paid based on school
attendance will be discontinued.
NOTE: The form will be signed by the student only if he or she has reached the age of majority and is receiving benefits in his or her own right. The
age of majority is determined by State law; it is age 18 in most States. Otherwise, the parent, guardian, or custodian will sign and also enter his or her
relationship to the student in Item 8.
5. OFFICIAL BEGINNING DATE OF REGULAR
TERM OF COURSE (Month, day,year)

6A. DID STUDENT START THE COURSE OF TRAINING?
YES (If "Yes," complete Item 6B)

6B. DATE STUDENT STARTED COURSE OF
TRAINING (Month, day, year)

NO (If "No," enter reason in Item 15)
7A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID UNDER VA DEPENDENTS' EDUCATIONAL ASSISTANCE (DEA),
FEDERAL EMPLOYEES' COMPENSATION ACT OR ANY OTHER FEDERAL AGENCY BENEFIT (U.S. SERVICE ACADENY, U.S. MERCHANT MARINE ACADEMY,
BUREAU OF INDIAN AFFAIRS, ETC.) OF THE UNITED STATES GOVERNMENT?
YES

NO

(If "Yes," complete Items 7B and 7C)

7B. TYPE OF BENEFIT

7C. DATE PAYMENTS BEGAN

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
8. SIGNATURE

9. RELATIONSHIP TO STUDENT

11A. DAYTIME TELEPHONE NUMBER (Including Area Code)

10. DATE SIGNED

11B. EVENING TELEPHONE NUMBER (Including Area Code)

PART II - VERIFICATION OF TERMINATION OF SCHOOL ATTENDANCE

(To Be Completed By School)

Information has been received that the student named in Item 4 discontinued his or her course of training at your school. Please complete Items 12
through 18 and return this form to the VA office shown in Item 2.
12A. DATE SCHOOL ATTENDANCE TERMINATED (Month, day, year)

12B. IS THIS THE OFFICIAL ENDING DATE OF REGULAR TERM FOR SUCH COURSE?
YES (If "Yes," complete Item 13A)

NO (If "No," complete Item 13B)

13A. BEGINNING DATE OF THE NEXT REGULAR TERM FOLLOWING
13B. OFFICIAL ENDING DATE OF REGULAR TERM (Month, day, year)
THE DATE STUDENT DISCONTINUED SCHOOL (Month, day, year)

14. REASON FOR TERMINATION OF ATTENDANCE

VA FORM
XXXX

21-674b

SUPERSEDES VA FORM 21-674b, SEP 2013,
WHICH WILL NOT BE USED.

PART II - VERIFICATION OF TERMINATION OF SCHOOL ATTENDANCE (Continued)

(To Be Completed By School)

15. REMARKS

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

17A. SIGNATURE OF SCHOOL OFFICIAL

17B. TITLE OF SCHOOL OFFICIAL

18. DATE

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 21-674b, XXXX

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