Form VA Form 22-10203 VA Form 22-10203 Edith Nourse Rogers STEM Scholarship Application

INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
EDITH NOURSE ROGERS STEM SCHOLARSHIP
(VA FORM 22-10203)
Use this form to apply for the Edith Nourse Rogers STEM Scholarship only. Other education benefits require different application forms that
are available on-line at www.va.gov/vaforms. This form can be completed on-line and then printed and mailed to the address shown
below.
IMPORTANT INFORMATION
NOTE: The Edith Nourse Rogers STEM Scholarship is intended for those Veterans who have used all of their remaining Post-9/11
(Chapter 33 educational assistance within 180 days of applying for this scholarship).
The VA or any other government agency may contact you to gather detailed information regarding the use of this scholarship, such as:
program completion, employment information, annual earnings or any other information deemed necessary.
The numbers on this Information and Instructions attachment match the item numbers on the application. Items not mentioned are selfexplanatory.

PART II - APPLICANT'S COURSE OF STUDY, CERTIFICATION AND SIGNATURE
ITEM 1B. CIP Code -This code is found next to the approved STEM programs listed on the VA Education website at
https:benefits.va.gov/gibill/fgib/stem.asp
ITEM 1D. Number of Standard Semester/Quarter Credit Hours Needed for Completion of Your Degree - Indicate how many credits
are still needed in order to complete your degree.

NOTE: To facilitate the prompt processing of your claim make sure that Part III has been completed, signed and dated by your school
Certifying Official.

PART III - INFORMATION TO BE COMPLETED BY THE SCHOOL CERTIFYING OFFICIAL
This part is to be completed by your school Certifying Official, and either submitted via email to [email protected] or by mail to the
address below.
Please submit application and any supporting documentation to:
VA Regional Processing Office
P.O. Box 4616
Buffalo, NY 14240
For more information about the Edith Nourse Rogers Scholarship, visit the STEM website at https://benefits.va.gov/gibill/fgib/stem.asp or
you can send your questions via email to [email protected].
ADDITIONAL HELP: If you need more help in completing this application, call VA Toll-Free at 1-888-GI-BILL-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 education assistance after
normal business hours at our education internet site at www.gibill.va.gov and www.benefits.va.gov/VOW.

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, section 1.576 for routine uses (e.g. VA sends educational forms or letters with a veteran's identifying information to
the veteran's school or training establishment to (1) assist the veteran in the completion of claims forms or (2) for the VA to obtain further information as may
be necessar4y from the school for the VA to properly process the veteran's education claim or to monitor his or her progress during training) 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 or retain 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. The 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 enacted before January 1, 1975, and still in effect. While you do not have to
respond. VA cannot process your claim for education assistance unless the information is furnished as required by Public Law 115-48. The responses you
submit are considered confidential (38 U.S.C. 5701.) Any information provided by applicants, recipients, and others may be subject to verification through
computer matching programs with other agencies.
Respondent Burden: We need this information to determine your eligibility to participate in the Edith Nourse STEM Scholarship, 38 CFR 36.4344, 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 the 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 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 22-10203 XXX XXXX

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OMB Control No. 2900-XXXX
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR EDITH NOURSE ROGERS STEM SCHOLARSHIP
INSTRUCTIONS: Read the Privacy Act and Respondent Burden on Page 1 before completing the form.
Applicant should complete Parts I and II. The school Certifying Official should complete Part III and
submit the completed form via email to [email protected] or by mail to: VA Regional Processing
Office, P.O. Box 4616, Buffalo, NY 14240.
PART I: APPLICANT INFORMATION AND DIRECT DEPOSIT
SECTION I: APPLICANT INFORMATION
NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing of the form.
1. NAME OF APPLICANT (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER OF APPLICANT

3. GENDER OF APPLICANT

4. APPLICANT'S DATE OF BIRTH
Month

MALE

Day

Year

FEMALE

5. APPLICANT'S MAILING ADDRESS (Number and Street or Rural Route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City
Country

State/Province

ZIP Code/Postal Code
7. PREFERRED TELEPHONE NUMBER OF APPLICANT (Include Area Code)

6. E-MAIL ADDRESS OF APPLICANT (Optional)

8. ARE YOU CURRENTLY ON ACTIVE DUTY OR DO YOU ANTICIPATE YOU WILL BE GOING ON ACTIVE DUTY WHILE RECEIVING THE STEM SCHOLARSHIP?
YES

NO

9. DO YOU CURRENTLY HAVE REMAINING ENTITLEMENT UNDER ANY VA EDUCATION BENEFITS?
NO

YES

(If "Yes," provide remaining number of Months_____________ and Days_______________ and check the benefit(s) box below)

Chapter 33 - Post -9/11 GI Bill
Chapter 30 - Montgomery GI Bill Educational Assistance Program (MGIB)
Chapter 1606 - Montgomery GI Bill - Selected Reserve Educational Assistance Program (MGIB-SR)
Chapter 32 or Section 903 - Post Vietnam Era Veterans' Educational Assistance Program (VEAP)
Chapter 35 - The Dependents Educational Assistance Act

SECTION II: DIRECT DEPOSIT INFORMATION

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 in Items 10, 11 and 12 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 encourage your participation in EFT and address any questions or
concerns you may have.
10. ACCOUNT NUMBER (Check only one box below and provide the account number)
CHECKING

SAVINGS

Account Number:________________________________
11. NAME OF FINANCIAL INSTITUTION (Provide the name of the bank where you
want your direct deposit sent)

VA FORM
XXX XXXX

22-10203

12. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the

bottom left of your check)

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PART II: APPLICANT'S COURSE OF STUDY, CERTIFICATION AND SIGNATURE
SECTION I - APPLICANT'S COURSE OF STUDY
1. TYPE OF EDUCATION PROGRAM THAT YOU ARE CURRENTLY ENROLLED IN (Check one)
Education Program that leads to an "Undergraduate Degree" in a standard, undergraduate college degree (See "Approved Stem Programs"
listed below) (If checked, complete Items A & B below).
A. PROGRAM NAME (See "Approved Stem Programs" list below):____________________________________
B. CIP CODE (See Information and Instructions Part II):____________________________________
Earned a degree from an Education Program listed under "Approved Stem Programs" and I am now enrolled in a program leading to a
"Teaching Certification"
2. PROVIDE THE LOCATION WHERE YOU PLAN TO OR WILL START TRAINING (City and State)

3. PROVIDE THE DATE YOU PLAN TO OR WILL START TRAINING
(MM/DD/YYYY)

BELOW IS A LISTING OF CURRENTLY APPROVED STEM PROGRAMS.
1. Biological or Biomedical Science
2. Physical Science
3. Science Technologies or Technicians
4. Computer and information science and support serivces
5. Mathematics or Statistics
6. Engineering
7. Engineering Technologies or an Engineering-related field
8. A health profession or related program
9. An agriculture science program or a natural resources science program
10. Other subjects and fields identified by the Secretary of Veterans Affairs as meeting national needs.
NOTE: For a complete list of approved STEM programs and their associated CIP codes, please visit our website at
https://benefits.va.gov/gibill/fgib/stem.asp
SECTION II - CERTIFICATION AND SIGNATURE OF APPLICANT
CERTIFICATION STATEMENT
THE INFORMATION PROVIDED ON THIS APPLICATION WILL BE USED FOR THE PURPOSES OF PRIORITIZING AND DETERMINING ELIGIBILITY
FOR APPLICANTS PARTICIPATING IN THE EDITH NOURSE ROGERS STEM SCHOLARSHIP FROM THE DEPARTMENT OF VETERANS AFFAIRS.
THE INFORMATION MAY BE AUDITED FOR ACCURACY. BY SIGNING BELOW, YOU AGREE TO THE FOLLOWING STATEMENT:
"I swear or affirm that the statements on this application, to the best of my knowledge are true and correct. I understand that by submitting this application, I am
making a statement to the government for the purposes of obtaining federal benefits. Section 1001 of Title 18 of the U.S. Code makes it a criminal offense for any
person to knowingly and willfully make false or fraudulent statements to any department or agency of the United States Government. Additionally, I understand that
if the information I have provided on this application is found to be false or incorrect. I will immediately be unable to receive benefits under this program, and I may
be required to reimburse the federal government for any benefits I have already received."
5. DATE SIGNED (MM/DD/YYYY)

4. SIGNATURE OF APPLICANT

PART III: INFORMATION TO BE COMPLETED BY SCHOOL CERTIFYING OFFICIAL
1. NAME OF STUDENT (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER OF STUDENT

3. NAME OF STEM PROGRAM STUDENT IS ENROLLED IN

5. PROVIDE HOURS COMPLETED AND HOURS REMAINING BY SEMESTER OR QUARTER
Hours completed:__________________(Semester)__________________(Quarter)

4. CIP CODE (Provide 6 digit CIP Code) (See
Information and Instructions Part II)

6. HAS THE STUDENT EARNED A UNDERGRADUATE DEGREE IN
A STEM PROGRAM AND IS CURRENTLY ENROLLED IN A
PROGRAM LEADING TO A TEACHING CERTIFICATION?
YES

NO

Hours remaining:__________________(Semester)__________________(Quarter)
7. SIGNATURE OF CERTIFYING OFFICIAL

VA FORM 22-10203, XXX XXXX

8. DATE SIGNED (MM/DD/YYYY)

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