Form VA Form 21-674 VA Form 21-674 Request for Approval of School Attendance

OMB Approved No. 2900-0049
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX

REQUEST FOR APPROVAL OF SCHOOL ATTENDANCE

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 3. Use
this form to determine entitlement to benefits for a veteran's child who is between the ages of 18 and 23 and
attending school. Want to apply electronically? You can apply online at https://www.va.gov/view-changedependents/view/. For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.
VA forms are available at www.va.gov/vaforms. After completing the form, use the mailing addresses
provided on Page 3 to submit.

SECTION I: VETERAN/CLAIMANT'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, and completely
fill in each applicable circle to help expedite processing of the form.
1. VETERAN/CLAIMANT'S NAME (First, Middle Initial, Last)

3. E-MAIL ADDRESS (Optional)

2. VA FILE NUMBER (If applicable)

SECTION II: STUDENT'S IDENTIFICATION INFORMATION
NOTE: If you would like to submit an additional student's information, use a separate form (VA Form 21-674) for each student.
4. STUDENT'S NAME (First, Middle Initial, Last) (NOTE: Veteran's child attending school)

5. SOCIAL SECURITY NUMBER

6. DATE OF BIRTH (MM/DD/YYYY)

7A. HAS STUDENT EVER MARRIED?

7B. DATE OF MARRIAGE (MM/DD/YYYY)

YES (If "Yes," complete Item 7B)

NO

8. ADDRESS OF STUDENT (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
ZIP Code/Postal Code

Country

SECTION III: SCHOOL ATTENDANCE INFORMATION
(If additional space is needed, use Section V: Remarks)
9A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID BY VA DEPENDENTS' EDUCATIONAL ASSISTANCE (DEA), THE
FEDERAL EMPLOYEE'S COMPENSATION ACT, OR ANY OTHER AGENCY OR PROGRAM OF THE UNITED STATES GOVERNMENT?
YES (If "Yes," complete Items 9B and 9C)

NO (If "No," skip to Item 10A)

9B. TYPE OF BENEFIT (i.e. GI Bill, Fry Scholarship, etc.)

9C. DATE PAYMENTS BEGAN (MM/DD/YYYY)

10A. MY DEPENDENT HAS ATTENDED SCHOOL CONTINUOUSLY
(NOTE: Normal breaks during the school year are not considered breaks in continuous enrollment)

10B. IS THE SCHOOL ACCREDITED?
YES

YES (If "Yes," complete Item 10B)

NO

NO (If "No," add the date your dependent stopped attending continuously) (MM/DD/YYYY)

11A. OFFICIAL BEGINNING DATE OF REGULAR
TERM OR COURSE (MM/DD/YYYY)

11B. DATE STUDENT STARTED OR EXPECTS TO
START COURSE (MM/DD/YYYY)

12A. WAS STUDENT ATTENDING ANY SCHOOL AT END
OF LAST SCHOOL TERM?

12B. BEGINNING DATE OF LAST TERM
(MM/DD/YYYY)

11C. EXPECTED DATE OF GRADUATION
(MM/DD/YYYY)

12C. ENDING DATE OF LAST TERM
(MM/DD/YYYY)

YES (If "Yes," complete Items 12B and 12C)
NO
VA FORM
XXX XXXX

21-674

SUPERSEDES VA FORM 21-674, JUN 2018.

Page 1

SECTION IV: STUDENT'S ATTENDANCE INFORMATION
(See Instructions on Page 3, for additional information)
13. REPORT OF INCOME BY CALENDAR YEAR
(IMPORTANT: Do NOT report VA benefits)
A. SOURCE

B. RECEIVED

C. EXPECTED

(Report for year in which school term begins - See Item 11)

(Report for year following Column B)

EARNINGS FROM ALL EMPLOYMENT

$

ANNUAL SOCIAL SECURITY

$

OTHER ANNUITIES

$

,
,
,
,

ALL OTHER INCOME (i.e. interest, dividends, etc.) $

.
.
.
.

$
$
$
$

,
,
,
,

.
.
.
.

14. VALUE OF ESTATE
A. SAVINGS (Including cash)

$

,
,
,
,

$

,

$

B. SECURITIES, BONDS, ETC.

$

C. REAL ESTATE (Not your home)

$

D. ALL OTHER ASSETS
E. TOTAL VALUE

,
,
,
,
,

.
.
.
.
.

SECTION V: REMARKS
15. REMARKS (If any)

SECTION VI: CERTIFICATION AND SIGNATURE
NOTE: This part will be completed by the student only if they have attained majority and are claiming benefits on their own behalf. Otherwise, the veteran,
surviving spouse, guardian or custodian will sign, date and enter their relationship to the student and telephone number in Items 16A through 16D.
Receipt by the student of VA Dependents' Educational Assistance (DEA), the Federal Employee's Compensation Act, or benefit from another Federal
Agency (i.e. U.S. Service Academy, U.S. Merchant Marine Academy, Bureau of Indian Affairs, etc.) with additional compensation payments based on the
student's school attendance is considered a duplication of benefits and is prohibited.
I CERTIFY THAT the information given above is true and correct to the best of my knowledge and belief and request approval of the education or training
shown above.
I AGREE to notify the Department of Veterans Affairs immediately of any changes in my education, transfer to another school, discontinuance of school
attendance, receipt of DEA, or marriage prior to completion of my education. I understand that continued entitlement to school attendance may be based
on information I have furnished on this form.
16A. VETERAN/CLAIMANT/STUDENT SIGNATURE (REQUIRED)

16C. RELATIONSHIP TO STUDENT

16B. DATE SIGNED (MM/DD/YYYY)

16D. TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)
PENALTY: The law provides severe penalties (including fine or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or for
fraudulent receipt of any document you are not entitled to.
VA FORM 21-674, XXX XXXX

Page 2

INSTRUCTIONS

NOTE: Read the instructions carefully before completing this form.
How do I complete VA Form 21-674?
VA Form 21-674 should be completed by the person receiving or claiming benefits for a veteran's child who is at least 18 but under 23
and attending school. The veteran's child should complete the form only if you have reached the age of majority and is or will be entitled
to receive direct payment of VA benefits. NOTE: The age of majority is determined by State law; it is age 18 in most states.
After completing this form, please use the related mailing address below to submit:
COMPENSATION CLAIMS
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444

PENSION & SURVIVORS BENEFIT CLAIMS
Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365

NOTE: Use VA Form 21-674b, School Attendance Report, to report to VA any change in the child's status, such as termination of
school attendance or marriage.
SECTION III
All claimants must complete this part. Answer "Yes" to Item 9A only if Federal Employee's Compensation, VA Dependents'
Educational Assistance (DEA), or another Federal Agency (i.e. U.S. Service Academy, U.S. Merchant Marine Academy, Bureau of
Indian Affairs, etc.) is paying the student's tuition. Do not answer "Yes" simply because Social Security benefits have been awarded
based on the student's continuing school attendance.
SECTION IV
Complete this part only if the benefit being claimed or received is disability Pension or Survivors' Pension. Each income block must be
completed. If you do not receive income from a particular source, write "0.00" in the boxes provided. Do not leave the space blank. VA
will interpret a blank space as "0" or "None". Report the gross amounts before you take out deductions for taxes, insurance, etc.
Section 306 or Old Law Pension (entitlement to pension established before January 1, 1979): Complete this part only if the VA benefit
payable will be death pension, and there is no surviving spouse entitled to death pension. Do not complete if the student is a dependent
on a veteran's or surviving spouse's award.
Improved Pension: Complete this part showing the student's income. Educational or vocational rehabilitation expenses are amounts
paid by the student for their course of post-secondary education or vocational rehabilitation, including tuition, fees, and materials. If any
of these expenses are paid by the student, the expenses may be deducted from the earned income of the student. Report the total amount
(s) paid and dates of payment in Section V: Remarks.
SECTION VI
This part will be completed by the student only if they have reached the age of majority and are claiming benefits on their own behalf.
Otherwise, the veteran, surviving spouse, guardian or custodian will sign, date and enter their relationship to the student and telephone
number in Items 16C and 16D.
NOTE: Any benefits allowed due to this form will be discontinued if the student marries, receives DEA benefits, leaves school, or
passes away.
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, 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 their 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 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.
VA FORM 21-674, XXX XXXX

Page 3