Form VA Form 21P-8926 VA Form 21P-8926 Certification of School Attendance - REPS

OMB Approved No. 2900-0394
Respondent Burden: 15 Minutes
Expiration Date: XXXXXXX

CERTIFICATION OF SCHOOL ATTENDANCE - REPS
IMPORTANT: The certification is requested on behalf of the student named below to determine entitlement to benefits. While you are not required to respond, your
cooperation in promptly completing and returning this form will be appreciated. The form should be returned using the fax number or mailing address specified in your
most recent claim letter from the Veterans Benefits Administration.
1. NAME AND ADDRESS OF SCHOOL

Privacy Act Notice: The 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, CFR 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 identify 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,
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. 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.

NOTE: REPS represents the Restored Entitlement Program For Survivors.
2. VETERAN'S/WAGE EARNER'S SOCIAL
SECURITY NUMBER

3. STUDENT'S NAME

4. STUDENT'S SOCIAL SECURITY NUMBER

5. ATTENDANCE

COMPLETE ALL ITEMS BELOW GIVING INFORMATION
ONLY FOR THE PERIOD INDICATED

A. FROM (Month, day, year)

B. TO (Month, day, year)

STUDENT CERTIFICATION

6. DURING THE PERIOD SHOWN IN ITEM 5:
I ATTENDED FULLI AM ATTENDING FULL-TIME D.
A.
TIME ONLY FOR THE
I
AM
NOT
ATTENDING
B.
PERIOD INDICATED IN
FULL-TIME
ITEM 6E (Provide dates of
I DID NOT ATTEND
C.
full-time attendance)

6E. DATES OF FULL-TIME ATTENDANCE INDICATED IN ITEM 6D
FROM (Month, day, year)

TO (Month, day, year)

I CERTIFY THAT the foregoing statement is true and correct to the best of my knowledge and belief.
7A. SIGNATURE OF STUDENT (Sign in ink)

7B. DATE

CERTIFICATION BY SCHOOL OFFICIAL
8. IS THE STUDENT ENROLLED IN FULL-TIME STATUS ACCORDING TO THE SCHOOL'S STANDARDS AND PRACTICES FOR THE PERIOD
SHOWN IN ITEM 5? (For evening students, use the same standards applicable to day students)
YES

NO

(If "No," complete Item 9)
A. FROM (Month, day, year)

9. ENTER BEGINNING AND ENDING DATES (UP TO THE
PRESENT) OF STUDENT'S FULL-TIME STATUS (If none,
enter "NONE") (If more space is needed, enter additional
information in Item 12, Remarks, and key answers to item numbers)

B. TO (Month, day, year)

10. TYPE OF SCHOOL
JUNIOR COLLEGE, COLLEGE OR
UNIVERSITY UNDERGRADUATE

COLLEGE GRADUATE

TO BE COMPLETED BY ALL SCHOOLS
EXCEPT JUNIOR COLLEGES, COLLEGES
OR UNIVERSITIES

TECHNICAL, TRADE
OR VOCATIONAL

OTHER
(Specify)

11. ENTER THE TOTAL CLOCK HOURS PER WEEK THE STUDENT IS/WAS
SCHEDULED TO ATTEND (Show any variation in scheduled attendance in Item 12,
Remarks, and key answers to item numbers)

12. REMARKS

Respondent Burden: This information is needed to determine your entitlement to Reps benefits. 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.

I CERTIFY THAT the foregoing statement is true and correct to the best of my knowledge and belief.
13A. SIGNATURE (Sign in ink) AND TITLE OF SCHOOL OFFICIAL

VA FORM
XXXX

21P-8926

13B. SCHOOL TELEPHONE NO.
(Include Area Code)

SUPERSEDES VA FORM 21-8926, MAR 2018,
WHICH WILL NOT BE USED.

13C. DATE