Form VA Form 22-5490 VA Form 22-5490 Dependents' Application for VA Education Benefits

OMB Approved No. 2900-0098
Respondent Burden: 45 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(For VA Use Only)

DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(Under Provisions of chapters 33 and 35, of title 38, U.S.C.)
INTERNET VERSION AVAILABLE - You may complete and submit your application online at: www.benefits.va.gov/gibill.
Request to Opt-Out of Information Sharing With Educational Institutions
By checking the box, I CERTIFY THAT THE DEPARTMENT OF VETERANS AFFAIRS (VA) does not have my permission to share information about my veterans'
education benefits with any educational institution. I understand that sharing my information with my school is intended to support the certification process and that
"opting-out" may delay that process. See Information and Instructions on Page 7 for more information.

PART I - APPLICANT INFORMATION
1. SOCIAL SECURITY NUMBER

3. DATE OF BIRTH

2. SEX OF APPLICANT
MALE

FEMALE

4. NAME (First name, middle initial, last name)

5. CURRENT MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

6. TELEPHONE NUMBER(S) (Including Area Code)
PRIMARY

SECONDARY

7. E-MAIL ADDRESS

8. DIRECT DEPOSIT (Attach a voided personal check or provide the following information. See instructions for additional information.)
ROUTING OR TRANSIT NUMBER

ACCOUNT NUMBER

ACCOUNT TYPE
CHECKING

SAVINGS

9. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
C. TELEPHONE NUMBER (Include Area Code)

B. ADDRESS

A. NAME

PART II - QUALIFYING INDIVIDUAL INFORMATION
10. NAME OF QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (First name, middle initial, last name)

11. SOCIAL SECURITY NUMBER OR VA FILE NUMBER

13. DATE OF BIRTH

12. BRANCH OF SERVICE

14A. DID PARENT OR SPOUSE DIE WHILE SERVING ON ACTIVE DUTY?
YES

NO

(If "Yes," is checked complete
Item 14B)

14B. DATE OF DEATH

(If "No," is checked then you do not qualify
for the FRY Scholarship)

14C. DATE LISTED AS MISSING IN ACTION
OR P.O.W.

15. IS QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON ACTIVE DUTY?
YES

NO

16. DO YOU (APPLICANT) OR THE QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
YES

NO

PART III - RELATIONSHIP AND BENEFIT INFORMATION
17. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL (Check only one)
SPOUSE/SURVIVING SPOUSE

CHILD/STEPCHILD/ADOPTED CHILD

(Please complete only Section I below, and then proceed to Part V)

(Please complete only Section II below, and then proceed to Part V)

SECTION I - SPOUSE/SURVIVING SPOUSE
18. IS A DIVORCE OR ANNULMENT PENDING TO THE
QUALIFYING INDIVIDUAL?
YES
VA FORM
XXX XXXX

NO

22-5490

19. IF YOU ARE THE SURVIVING SPOUSE, HAVE YOU REMARRIED?
YES

NO

(If "Yes," please provide date of remarriage)

SUPERSEDES VA FORM 22-5490, JUN 2017,
WHICH WILL NOT BE USED.

PAGE 1

SOCIAL SECURITY NUMBER OF APPLICANT
SECTION I - SPOUSE/SURVIVING SPOUSE (Continued)
20. SPOUSE/SURVIVING SPOUSE SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW:
PLEASE CAREFULLY READ THE INFORMATION AND INSTRUCTIONS PAGE 5, ITEM 20 BEFORE SELECTING BOX "A" OR "B"
BELOW REGARDING THE BENEFIT YOU ARE APPLYING FOR. THE INSTRUCTION PAGE 5 ALSO PROVIDES LINKS TO THE
VA WEBSITE WHERE YOU WILL BE ABLE TO COMPARE THE DIFFERENCE BETWEEN "DEA" AND "FRY" BENEFITS. YOU WILL
ALSO FIND OTHER ELIGIBILTIY RELATED INFORMATION.

IMPORTANT ►
A.

AS A SPOUSE OR SURVIVING SPOUSE BASED ON 100%
PERMANENT AND TOTAL DISABILITY, SERVICE CONNECTED
OR LINE OF DUTY DEATH, I AM APPLYING FOR
CHAPTER 35 - DEA BENEFITS

NOTE - BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.

B.

AS A SURVIVING SPOUSE BASED ON LINE OF DUTY
DEATH AFTER SEPTEMBER 10, 2001, I AM APPLYING
FOR CHAPTER 33 - FRY SCHOLARSHIP BENEFITS

NOTE - BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.

SECTION II - CHILD/STEPCHILD/ADOPTED CHILD
21. CHILD/STEPCHILD/ADOPTED CHILD SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW:
PLEASE CAREFULLY READ THE INFORMATION AND INSTRUCTIONS PAGE 6, ITEM 21 BEFORE SELECTING BOX "A" OR "B"
BELOW REGARDING THE BENEFIT YOU ARE APPLYING FOR. THE INSTRUCTION PAGE 5 ALSO PROVIDES LINKS TO THE
VA WEBSITE WHERE YOU WILL BE ABLE TO COMPARE THE DIFFERENCE BETWEEN "DEA" AND "FRY" BENEFITS. YOU
WILL ALSO FIND OTHER ELIGIBILTIY RELATED INFORMATION.

IMPORTANT ►
A.

I AM APPLYING FOR CHAPTER 35 - DEA BENEFITS

B.

I AM APPLYING FOR CHAPTER 33 - FRY SCHOLARSHIP
BENEFITS

NOTE: BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.

NOTE: BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.

Important - If your parent died in the line of duty prior to August 1, 2011, you may apply
for both DEA and FRY Scholarship benefits.
If you are eligible for both Chapter 35 (DEA) and Chapter 33 (FRY Scholarship) benefits
and you would like to use the Chapter 35 benefit first check the box below.

Important - If your parent died in the line of duty prior to August 1, 2011, you may
apply for both DEA and FRY Scholarship benefits.
If you are eligible for both Chapter 35 (DEA) and Chapter 33 (FRY Scholarship)
benefits and you would like to use the Chapter 33 benefit first check the box below.

CHAPTER 33 - FRY SCHOLARSHIP

CHAPTER 35 - DEA

IMPORTANT: If you are over the age of 18 once you receive either the DEA or FRY Scholarship benefits, you will no longer receive payments of Dependency and
Indemnity Compensation (DIC) or Pension and you may no longer be claimed as a dependent in a Compensation claim. If you are under the age of 18, on your 18th
birthday you will lose eligibility for DIC or Pension payments and you will no longer be claimed as a dependent in a Compensation claim.
CAREFULLY READ THE INFORMATION AND INSTRUCTIONS PAGE 6, ITEM 22 BEFORE COMPLETING THE ELECTION BOX BELOW. YOU
ARE STRONGLY ENCOURAGED TO DISCUSS YOUR ELECTION WITH A VA COUNSELOR.
22. I CERTIFY THAT I UNDERSTAND THE EFFECTS THAT THIS ELECTION TO RECEIVE DEA OR FRY SCHOLARSHIP BENEFITS WILL HAVE ON MY ELIGIBILITY
TO RECEIVE DIC OR PENSION BENEFITS (Please read Information and Instructions Page 6 for additional information)
YES

NO

PART IV - BENEFIT AND TYPE OF EDUCATION OR TRAINING INFORMATION
23A. DATE YOU WILL BEGIN SCHOOL OR TRAINING (MM/DD/YYYY)
23B. TYPE OF EDUCATION OR TRAINING (Check ONE box)
COLLEGE OR OTHER SCHOOL
FARM COOPERATIVE
LICENSING OR CERTIFICATION TEST
APPRENTICESHIP OR OTHER ON-THE-JOB TRAINING
NATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDIT
CORRESPONDENCE COURSE
FLIGHT TRAINING (FRY Scholarship only)
23C. [ DEA ONLY] DO YOU HAVE A MENTAL OR PHYSICAL DISABILITY FOR

WHICH YOU ARE SEEKING SPECIAL RESTORATIVE TRAINING?
(See Information and Instructions, Page 6, for details regarding restorative training)
YES
NO

VA FORM 22-5490, XXX XXXX

23D. [ DEA ONLY] DO YOU HAVE A MENTAL OR PHYSICAL

DISABILITY FOR WHICH YOU ARE SEEKING SPECIAL
VOCATIONAL TRAINING? (See Information and Instructions,
Page 6, for details regarding special vocational training)
YES
NO

PAGE 2

SOCIAL SECURITY NUMBER OF APPLICANT
24A. NAME AND ADDRESS OF SCHOOL OR TRAINING FACILITY (Number and street or rural route, city or P.O., State and ZIP Code)

24B. IN WHAT STATE DO YOU ANTICIPATE LIVING WHILE PARTICIPATING IN THIS TRAINING? (You must notify us immediately if the state in which you live

changes from the state indicated below)

PROVIDE TWO-LETTER POSTAL ABBREVIATION CODE IN THE BOXES:
25. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE, IF KNOWN (e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer)
26. WOULD YOU LIKE TO RECEIVE VOCATIONAL AND EDUCATIONAL COUNSELING? (See Instructions, Item 26 for more information regarding vocational

and educational counseling)
NO

YES

PART V - APPLICATION HISTORY
27. PRIOR TO THIS APPLICATION, HAVE YOU EVER APPLIED FOR OR RECEIVED ANY OF THE FOLLOWING VA BENEFITS? (Check all appropriate boxes)
A.

DISABILITY COMPENSATION OR PENSION

B.

DEPENDENTS' INDEMNITY COMPENSATION (DIC)

C.

VOCATIONAL REHABILITATION BENEFITS (Chapter 31)

D.

VETERANS EDUCATION ASSISTANCE BASED ON YOUR OWN SERVICE (Specify benefit(s):

E.

VETERANS EDUCATION ASSISTANCE BASED ON SOMEONE ELSE'S SERVICE
SPECIFY BENEFIT(S) BY CHECKING APPLICABLE BOX BELOW AND COMPLETE ITEMS 28 AND 29
TRANSFERRED ENTITLEMENT
CHAPTER 35 - SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE PROGRAM (DEA)
CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY SERGEANT DAVID FRY SCHOLARSHIP

F.

NONE

G.

OTHER (Specify benefit(s):

IMPORTANT: Complete Items 28 and 29 only if you checked the box for Item 27E above.
28. NAME OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS (First, Middle, Last)
29. SOCIAL SECURITY NUMBER OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS

PART VI - APPLICANT'S MILITARY SERVICE INFORMATION
(NOTE: Chapter 35 benefits are not payable while an eligible person is on active duty)
30. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES? (If "No," skip to Part VII)
YES

NO

31. INFORMATION ABOUT YOUR PERIOD(S) OF ACTIVE DUTY (If you need additional space use Item 37, Remarks)
A. DATE ENTERED ACTIVE DUTY

B. DATE SEPARATED
FROM ACTIVE DUTY

C. BRANCH OF SERVICE OR
RESERVE OR GUARD COMPONENT

D. CHARACTER OF DISCHARGE

PART VII - EDUCATION, TRAINING AND EMPLOYMENT
SECTION I - EDUCATION & TRAINING
32. CHECK THE APPROPRIATE BOX AND ENTER THE DATE IN ITEM 33
GRADUATED FROM HIGH SCHOOL

DISCONTINUED HIGH SCHOOL

EXPECT TO GRADUATE FROM HIGH SCHOOL

AWARDED GED

34A. TYPE
OF SCHOOL

34B. NAME AND LOCATION
OF SCHOOL
(City and State)

34C. DATES OF TRAINING
FROM

TO

NEVER ATTENDED
HIGH SCHOOL

33. DATE

34E. DEGREE, DIPLOMA
34D. NUMBER OF
SEMESTER, QUARTER, OR
OR CERTIFICATE
CLOCK HOURS COMPLETED
RECEIVED

34F. MAJOR FIELD OR
COURSE OF STUDY

HIGH SCHOOL
COLLEGE
VOCATIONAL
OR TRADE
OTHER

(Specify)

VA FORM 22-5490, XXX XXXX

PAGE 3

SOCIAL SECURITY NUMBER OF APPLICANT

PART VII - EDUCATION, TRAINING AND EMPLOYMENT (Continued)
SECTION II - EMPLOYMENT
35. CURRENT AND PAST EMPLOYMENT
A. EMPLOYER

C. NUMBER OF MONTHS
EMPLOYED

B. JOB TITLE

D. LICENSE OR RATING

NOTE: Complete Item 36 only if you are a civilian employee of the U.S. Government.
36A. DO YOU EXPECT TO RECEIVE FUNDS FROM YOUR AGENCY OR
DEPARTMENT FOR THE SAME COURSES FOR WHICH YOU EXPECT TO
RECEIVE VA EDUCATIONAL ASSISTANCE? (If "Yes," complete Item 36B)
YES

36B. SOURCE OF EDUCATIONAL ASSISTANCE FROM GOVERNMENT
EMPLOYMENT

NO

PART VIII - REMARKS, REMINDERS AND VA EDUCATION BENEFITS PAMPHLET
SECTION I - REMARKS
37. REMARKS (If more space is needed, please attach a separate sheet of paper. Be sure to include name and social security number on each sheet)

SECTION II - REMINDERS
DID YOU REMEMBER TO:
• WRITE YOUR SOCIAL SECURITY NUMBER ON EACH PAGE
• WRITE YOUR COMPLETE MAILING ADDRESS
• ATTACH SUPPORTING DOCUMENTS (e.g., birth certificate, marriage license, DD214, etc.)
SECTION III - VA EDUCATION BENEFITS PAMPHLET
38. THE MOST CURRENT INFORMATION ON VA EDUCATION BENEFITS IS AVAILABLE ONLINE AT www.benefits.va.gov/gibill. IF YOU WOULD LIKE A COPY OF THE
VA EDUCATION BENEFITS PAMPHLET PLEASE CHECK THE BOX.

PART IX - CERTIFICATION AND SIGNATURE OF APPLICANT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.
39A. SIGNATURE OF APPLICANT (DO NOT PRINT)

39B. DATE SIGNED

SIGN HERE ►
IN INK

PENALTY: Willfully false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the forfeiture of these or other
benefits and in criminal penalties.

PART X - SIGNATURE OF PARENT, GUARDIAN OR CUSTODIAN
(This section must be completed by the parent, guardian, or custodian if the applicant is a minor)
40. NAME OF PARENT, GUARDIAN, OR CUSTODIAN (First, Middle Initial, Last) (Type or print)

41. MAILING ADDRESS OF PARENT, GUARDIAN, OR CUSTODIAN
Number and Street
Apt./Unit Number
City, State, ZIP Code
42A. TELEPHONE NUMBERS OF PARENT, GUARDIAN, OR CUSTODIAN (Include Area Code)
Secondary:

Primary:
42B. E-MAIL ADDRESS OF PARENT, GUARDIAN, OR CUSTODIAN (If applicable)
43A. SIGNATURE OF: (Check one)
PARENT

GUARDIAN

VA FORM 22-5490, XXX XXXX

CUSTODIAN

SIGN HERE ►
IN INK
(DO NOT PRINT)

43B. DATE SIGNED

PAGE 4

(Please retain these Information and Instructions Pages for future reference)
INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(VA FORM 22-5490)
Do not use this form to apply for Veterans' education assistance based on your own service (chapters 30, 32, 33, 1606, or
1607) or vocational rehabilitation benefits (chapter 31). To apply for veterans' education assistance based on your own
service, use VA Form 22-1990. To apply for vocational rehabilitation benefits, use VA Form 28-1900.
INTERNET VERSION AVAILABLE - You may complete and submit this application on-line at www.benefits.va.gov/gibill. Click on "GI
Bill: Apply for Benefits."
NOTE: The numbers on the instructions page match the item numbers on this application. Items not mentioned are self-explanatory.
ITEM 8. 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 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 address any questions or concerns you may have and encourage your participation in EFT.
ITEM 16. You will not be eligible to receive benefits for any period for which you or the qualifying individual on whose account you are claiming benefits
has an outstanding felony warrant. Any benefits paid to you for such period will result in an overpayment and be subject to collection.
ITEM 17. If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your
spouse resided at the time of marriage or where you and/or your spouse resided when you filed your claim (or a later date when you became eligible for
benefits) (38 U.S.C.§ 103(3)). Additional guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.
ITEM 20. IMPORTANT - PLEASE READ THE INFORMATION BELOW BEFORE MAKING YOUR SELECTION IN ITEM 20A OR 20B REGARDING
THE BENEFIT YOU ARE APPLYING FOR.
• To qualify for the Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship you must be the surviving spouse of an
individual who died in the line of duty while serving on active duty as a member of the Armed Forces after September 10, 2001.
• To qualify for Survivor's and Dependents' Educational Assistance (DEA) you must be either:
(1) The spouse of a veteran who is permanently and totally disabled as a result of a service-connected disability, OR
(2) The spouse of an individual on active duty who has been listed as missing in action, captured in the line of duty by hostile
force, forcibly detained or interned in the line of duty by hostile force, or forcibly detained or interned in the line of duty by
a foreign government or power for more than 90 days, OR
(3) The surviving spouse of a veteran who died of a service-connected disability or who dies while a service-connected disability
was rated permanent and total in nature, OR
(4) The surviving spouse of an individual on active duty for which the evidence shows that the individual is hospitalized for receiving
outpatient medical care services or treatment; has a total disability permanent in nature incurred or aggravated in the line of duty
in the active military, naval, or air service; and the service person is likely to be discharged or released from such service for such
disability.
NOTE: If you are eligible for both Chapter 35 Survivors' and Dependents' Educational Assistance Program (DEA) and Chapter 33 Post-9/11 GI Bill
Marine Gunnery Sergeant John David Fry Scholarship (FRY Scholarship) benefits, you must relinquish/give up entitlement to one or the other benefit for
which you are eligible, even if eligibility is due to:
•
•
•
•

A Separate Period of Service (POS) to which the death of the parent is associated; OR
A POS based on a spouse who has a total disability permanent in nature resulting from a service-connected disability; OR
A POS based on any other criteria as listed in 38 U.S.C. § 3501(a)(1); OR
Death of any other individual identified in Item 10 of this application.

You cannot retain eligibility for both programs. Therefore, by checking either box "A" or box "B" in Item 20, you agree and understand that you are
making an irrevocable election to receive the selected benefit and your election may not be changed.
Important: Eligibility for (DEA) will be terminated in the event that VA determines that the individual on whose account benefits are claimed is no longer
totally disabled or VA is notified that the individual is no longer listed as captured, missing in action, or forcibly detained.
Note: Before making your election selection, you can compare the differences between (DEA) and (FRY), and the benefits each provide in order
to help you make the best choice that suits your needs.This benefit comparison information can be found on the VA website at:
https://www.benefits.va.gov.gibill/docs/factsheets/fry_scholarship.pdf. You can also find additional information about each program by visiting the
GI Bill website at: https://benefits.va.gov/gibill/ and using the comparison tool.

VA FORM 22-5490, XXX XXXX

PAGE 5

INFORMATION AND INSTRUCTIONS (Continued)
ITEM 21. IMPORTANT - PLEASE READ THE INFORMATION BELOW BEFORE MAKING YOUR SELECTION IN ITEM 21A OR 21B REGARDING
THE BENEFIT YOU ARE APPLYING FOR.
• To qualify for the Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship, you must be the dependent child of an
individual who died in the line of duty while serving on active duty as a member of the Armed Forces after September 10, 2001.
• The qualifying information provided on the Information and Instructions page 5 under Item 20 also applies to a dependent child.
Your decision to elect one benefit over another is irrevocable and CANNOT be changed once you have submitted this application.
PARENT'S DEATH PRIOR TO AUGUST 1, 2011 • The election you choose in Item 21 does not eliminate eligibility for the alternate education benefit for a child eligible
for Survivor's and Dependents' Educational Assistance (DEA) and the Chapter 33 Post-9/11 GI Bill Marine Gunnery
Sergeant John David Fry Scholarship (FRY Scholarship) based on a Service-member's "Line of Duty" death that occurred
prior to August 1, 2011.
PARENT'S DEATH ON OR AFTER AUGUST 1, 2011 •

If you are eligible for Chapter 35 Survivors' and Dependents' Educational Assistance Program (DEA) and eligible for
Chapter 33 Post-9/11 GI Bill Marine Sergeant John David Fry Scholarship (Fry Scholarship), and your parent died on
or after August 1, 2011, you must relinquish/give up eligibility entitlement to the benefit that you are not applying for;
even if eligibility is due to:
• Separate Periods of Service to which the death of the parent is associated;
• The death of any other individuals not identified in this application;
• Based on any other criteria as listed in 38 U.S.C. § 3501(a)(1); OR
• Death of any other individual identified in Item 10 of this application.

You cannot retain eligibility for both programs simultaneously. By checking either the box "A" or "B" in Item 21, you agree and understand that
you are making an irrevocable election to receive the selected benefit and your election selection may not be changed.
Important: Eligibility for (DEA) will be terminated in the event that VA determines that the individual on whose account benefits are claimed is no longer
totally disabled or VA is notified that the individual is no longer listed as captured, missing in action, or forcibly detained.
Note: Before making your election selection, you can compare the differences between (DEA) and (FRY), and the benefits each provide in order in order
to help you make the best choice that suits your needs.This benefit comparison information can be found on the VA website at:
https://www.benefits.va.gov/gibill/docs/factsheets/fry_scholarship.pdf. You can also find additional information about each program by visiting the
GI Bill website at: https://benefits.va.gov/gibill/ and using the comparison tool.
IMPORTANT - EFFECTIVE DATE
Child - If you elected to receive education benefits instead of Dependency and Indemnity Compensation (DIC), your election will be effective on the date
shown in Item 39B or the date VA receives this application, whichever is earlier.
Surviving Spouse - Your election will be effective on the date shown in Item 39b or the date VA receives this application, whichever is earlier.
ITEM 22. Your election to receive Survivors' and Dependents' Education Assistance (DEA) or Chapter 33 Post-9/11 GI Bill Marine Gunnery Sergeant
John David Fry Scholarship (Fry Scholarship) in lieu of payments of compensation, pension, and Dependents' Indemnity Compensation (DIC) is final
and cannot be changed. This means that if you are 18 years old, payments of compensation, pension, and Dependents' Indemnity Compensation (DIC)
will be terminated upon issuance of a DEA or Fry Scholarship benefit payment. If you are under the age of 18, these benefits will be terminated on your
18th birthday. If you are planning to pursue a program of education for more than 36 months, you should consider deferring receipt of DEA or Fry
Scholarship benefits. We strongly recommend that you discuss your education or training plans with a VA counselor before making a decision.
ITEM 23B. Types of education or training programs are self-explanatory, except for the following:
"Licensing or Certification Test" - A "licensing test" is a test offered by a state, local, or federal agency that is required by law to practice an
occupation. A "certification test" is a test designed to provide affirmation of an individual's qualifications in a specific occupation.
"National Admission Exams or National Exams for Credit" - Individuals eligible to receive benefits under the Survivors' and Dependents' Educational
Assistance program may be reimbursed for the cost of approved tests for admission to or credit at institutions of higher learning.
"Correspondence Course" - Only spouses and surviving spouses eligible for the Survivors' and Dependents' Educational Assistance program may
receive benefits for correspondence training. Payments for correspondence courses are made quarterly after VA receives a certification showing the
number of lessons completed. For more information on correspondence courses, you can go to the VA website at www.benefits.va.gov/gibill.
"Flight Training" - You must already have a private pilot's license. If you are taking an Airline Transport Pilot course, you must have a valid first-class
medical certificate on the date that you enter training. For all other flight courses, you must have a valid second-class medical certificate on the date that
you enter training.
ITEMS 23C AND 23D - Any individual eligible under the Survivors' and Dependents' Educational Assistance program may receive Special Restorative
Training or Specialized Vocational Training if a VA counselor determines that a specialized program is needed to overcome the effects of a physical or
mental handicap. To be eligible for receipt of specialized training, the disability must prevent you from pursuing an educational program. Examples of
Special Restorative Training include speech and voice correction, language retraining, lip reading, and Braille reading and writing. Specialized
Vocational Training consists of specialized courses leading to a suitable vocational objective.
ITEM 26 - VA VOCATIONAL AND EDUCATIONAL COUNSELING HELP AVAILABLE: VA offers a wide range of services to assist you in planning
your educational and/or career goals. Services include educational and vocational guidance and testing to develop a greater understanding of your
skills, talents and interests. For more information on VA counseling, call VA toll-free at 1-888-GIBILL-1 (1-888-442-4551) or if you use the
Telecommunications Device for the Deaf (TDD), the Federal Relay number is 711.
VA FORM 22-5490, XXX XXXX

PAGE 6

HOW TO FILE YOUR CLAIM
You may complete and submit your application online at www.benefits.va.gov/gibill or be sure to do the following:
(A) If you have selected a school or training establishment:
Step 1: Mail the completed application to the VA Regional Processing Office for the region of that school's physical address.
See page 8 for addresses of the VA Regional Processing Offices.
Step 2: Tell the veterans certifying official at your school or training establishment that you have applied for VA education
benefits. Ask him or her to submit your enrollment information using VA Form 22-1999, Enrollment Certification, or its electronic
version.
Step 3: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.
(B) If you have not selected a school or training establishment:
Step 1: Mail the completed application to the VA Regional Processing Office for the region of your home address. Check page 8
for addresses of the VA Regional Processing Offices.
Step 2: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.

REQUEST TO OPT-OUT OF INFORMATION SHARING WITH EDUCATIONAL INSTITUTIONS
The Harry W. Colmery Veterans Educational Assistance Act of 2017 (Public Law 115-48), also known as the "Forever GI Bill,"
requires the Department of Veterans Affairs (VA) to make available to educational institutions information about the amount of
educational assistance to which a veteran or other individual is entitled. However, you may elect to "opt-out" of these
disclosures and have VA withhold this information instead.

ADDITIONAL HELP COMPLETING APPLICATION
If you need additional help completing this application or you want information about the work-study program, call VA
toll-free at 1-888-GIBILL-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 more information about education assistance from our education
Internet site at www.benefits.va.gov/gibill.

CONTACT VA FROM OVERSEAS
Students and School Certifying Officials calling from outside the United States can contact VA by phone at:
001-918-781-5678 during business hours, 7 a.m. - 6 p.m. CST, Monday - Friday. This is not a toll-free number but the
caller will be routed to the next available customer service representative. Non-overseas customers should call the tollfree number shown in "Additional Help Completing Application".

VA FORM 22-5490, XXX XXXX

PAGE 7

Eastern Region:
VA Regional Office
P. O. Box 4616
Buffalo, NY 14240-4616

Western Region:
VA Regional Office
P. O. Box 8888
Muskogee, OK 74402-8888

SERVES THE FOLLOWING STATES

SERVES THE FOLLOWING STATES

CT

DE

DC

MA

AK

AL

AR

AZ

MD

ME

NC

NH

CA

FL

GA

HI

NJ

NY

PA

RI

ID

LA

MS

NM

VA

VT

US Virgin
Islands

Foreign
Schools

NV

OK

OR

PR

SC

TX

UT

WA

Guam

Philippines

APO/FPO AA

APO/FPO AP

Central Region:
VA Regional Office
P. O. Box 32432
St. Louis, MO 63132-0832
SERVES THE FOLLOWING STATES

CO

IA

IL

IN

KS

KY

MI

MN

MO

MT

NE

ND

OH

SD

TN

WV

WI

WY

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., awards of benefits) 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
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. 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 requested information is considered relevant and necessary to determine the maximum benefits allowable under the law. While you do not have to
respond, VA cannot process your claim for benefits unless the information is furnished as required by existing law (38 U.S.C. 3513). 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 your eligibility for education benefits (38 U.S.C. 3513). Title 38 U.S.C. allows us to ask for this
information. We estimate that you will need an average of 45 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 http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-888-GIBILL-1 (1-888-442-4551) to get information on where to send comments or suggestions about this form.

VA FORM 22-5490, XXX XXXX

PAGE 8