22-8692a Extended Student Work-Study Agreement

OMB Control No. 2900-0209
Respondent Burden: 3 minutes
Expiration Date: XX/XX/XXXX

EXTENDED STUDENT WORK-STUDY AGREEMENT
NAME:

VA FILE NUMBER:

(Last, First, Middle)

AGREEMENT NUMBER:

NOTE: VA will complete the hourly rate item below with the federal minimum wage or your State minimum wage rate, whichever is
greater. If you have any questions concerning this hourly rate, contact the Education Call Center at 1-888-442-4551.

I,
(student), wish to extend my work-study agreement with the Department
of Veterans Affairs (VA). I agree to perform
hours of service for VA during the period starting
on or about
and ending no later than
.
per hour for a total extended work-study allowance of
VA agrees to pay me at the rate of $
$
. I agree to abide by the conditions set forth in my initial agreement. I also understand that I
will not receive an advance payment under this extended agreement.
NOTE: The extended agreement may not begin earlier than the starting date shown above. This form is for
extended work-study agreements only. VA Form 22-8692b, or 22-8692 (if the student requests an advance
payment) must be used for initial work-study agreements. Those forms contain the conditions of the agreement.
Those conditions apply to the extended agreement. The student and the appropriate VA official must sign both
agreements.
This extended agreement is authorized under 38 U.S.C. 3485. It will become effective when signed by the
student and accepted by the VA official shown below.
PRIVACY ACT INFORMATION: VA will not disclose information collected by this information collection to any source other than what has been
authorized by the Privacy Act of 1974 or Title 38 Code of Federal Regulations 1.576 for routine uses as identified in VA's system of records,
58VA21/22/28, Compensation, Pension, Education and Veteran Readiness and Employment Records - VA as published in the Federal Register at
http://www.rms.oit.va.gov/SOR_Records/58VA21_22.asp. An example of a routine use allows VA to send 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
VA to obtain further information as may be necessary from the school for VA to properly process the veteran's education claim or to monitor his or
her progress during training. Your obligation to respond is "required to obtain or retain benefits". We cannot take any action to extend your workstudy contract until we receive this information (38 U.S.C. 3485). Your responses are 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 for an extension of your work-study contract shown on this
information collection. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 3 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 if this number is not displayed. Valid OMB control
numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRASearch. If desired, you can call 1-888-GI-BILL-1
(1-888-442-4551) to get information on where to send comments or suggestions about this information collection.
SIGNATURE OF STUDENT (Sign in ink)

DATE

CURRENT MAILING ADDRESS OF STUDENT (Number and street or rural route,

city or P.O., State and ZIP Code)

VA FORM
NOV 2020

22-8692a

SIGNATURE OF VA OFFICIAL (Sign in ink)

DATE

PERMANENT MAILING ADDRESS OF STUDENT, IF DIFFERENT (Include No.

and street or rural route, city, State and ZIP Code)

SUPERSEDES VA FORM 22-8692A, JAN 2018,
WILL BE USED.