VA Form 21-674b School Attendance Report

OMB Approved No. 2900-0049
Respondent Burden: 5 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

SCHOOL ATTENDANCE REPORT
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent
Burden on page 2. Use this form to report to VA any change in the child's status, such
as termination of school attendance or marriage. Want to apply electronically? You
can apply online at https://www.va.gov/view-change-dependents/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.

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)

2. VA FILE NUMBER (If applicable)

3. E-MAIL ADDRESS (Optional)

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

5. SOCIAL SECURITY NUMBER

6B. DATE OF MARRIAGE (MM/DD/YYYY)

6A. HAS STUDENT MARRIED?
YES (If "Yes," complete Item 6B)

NO

SECTION III: VERIFICATION OF SCHOOL ATTENDANCE
(To be completed by CLAIMANT)
INSTRUCTIONS: Benefits have been awarded because the student named in Item 4 expects to start a course of training. Provide verification if the
student started the course of training or needs to terminate benefits due to another reason or if in receipt of; VA Dependents' Educational Assistance
(DEA), the Federal Employee's Compensation Act, or any other agency or program (i.e. U.S. Service Academy, U.S. Merchant Marine Academy,
Bureau of Indian Affairs, etc.) of the United States government. Mail this form to one of the addresses provided on page 2, within 60 days after the date
the student begins the course. If the form is not returned, benefits paid based on school attendance will be discontinued.
7A. OFFICIAL BEGINNING DATE OF REGULAR TERM OR COURSE
(MM/DD/YYYY)

7B. DID STUDENT START THE COURSE OF TRAINING?
YES (If "Yes," complete Item 7C)

7C. DATE STUDENT STARTED COURSE OF TRAINING
(MM/DD/YYYY)

NO (If "No," enter reason in Section VII: Remarks)

8A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING
BEING PAID UNDER DEA, THE FEDERAL EMPLOYEE'S COMPENSATION ACT, OR
ANY OTHER FEDERAL AGENCY OR PROGRAM OF THE UNITED STATES GOVERNMENT?
YES (If "Yes," complete Items 8B and 8C)

8B. TYPE OF BENEFIT (i.e. GI Bill, Fry Scholarship, etc.)

NO

8C. DATE PAYMENTS BEGAN (MM/DD/YYYY)

SECTION IV: CERTIFICATION AND SIGNATURE OF STUDENT
SECTION IV: CERTIFICATION AND SIGNATURE OF CLAIMANT
NOTE: This part will be completed by the student only if they have attained majority and is claiming benefits on their own behalf. Otherwise, the veteran, surviving spouse,
guardian or custodian will sign and enter their relationship to the student.
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.
NOTE: The form will be signed by the student only if they have reached the age of majority and are receiving benefits on their own behalf. The age of majority is determined by
State law; it is age 18 in most States. Otherwise, the parent, guardian, or custodian will sign, date and enter their relationship to the student and telephone number in Items 9A
and 9D.
9B. DATE SIGNED (MM/DD/YYYY)
9A. VETERAN/CLAIMANT/STUDENT SIGNATURE (REQUIRED)

9C. RELATIONSHIP TO STUDENT

9D. TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)
VA FORM
XXX XXXX

21-674b

SUPERSEDES VA FORM 21-674b, JUN 2018.

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SECTION V: VERIFICATION OF TERMINATION OF SCHOOL ATTENDANCE
(To be completed by SCHOOL)
INSTRUCTIONS: Information has been received that the student named in Item 4 discontinued their course of training at your school. Please complete
Items 9 through 11, and Section VI: Remarks, if additional space is needed.
10A. DATE SCHOOL ATTENDANCE TERMINATED (MM/DD/YYYY)

10B. IS THIS THE OFFICIAL ENDING DATE OF REGULAR TERM FOR SUCH COURSE?
NO (If "No," complete Item 11B)

YES (If "Yes," complete Item 11A)
11A. BEGINNING DATE OF THE NEXT REGULAR TERM FOLLOWING THE
DATE STUDENT DISCONTINUED SCHOOL (MM/DD/YYYY)

11B. OFFICIAL ENDING DATE OF REGULAR TERM
(MM/DD/YYYY)

12. REASON FOR TERMINATION OF SCHOOL ATTENDANCE (If additional space is needed, use Section VII: Remarks)

SECTION VI: CERTIFICATION AND SIGNATURE OF SCHOOL OFFICIAL
I CERTIFY THAT the information given above is true and correct to the best of my knowledge and belief.
13A. SIGNATURE OF SCHOOL OFFICIAL (REQUIRED)

13B. DATE SIGNED (MM/DD/YYYY)

13C. TITLE OF SCHOOL OFFICIAL

SECTION VII: REMARKS
(This section can be used by either the claimant or the school)
14. REMARKS (If any)

Where to Send Your Correspondence - After completing this form, please use the related mailing address:

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

PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting statement or evidence of a material fact, you
know to be false, or for fraudulent receipt of any document you are not entitled to.
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 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 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: Use this form to report to VA any change in the child's status, such as termination of school attendance or marriage. Title
38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 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 21-674b, XXX XXXX

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