Form 22-6553d-1 Monthly Certification of On-The-Job and Apprenticeship T

OMB Approved No. 2900-0178
Respondent Burden: 10 Minutes
Expiration Date: XXXXXXXXX

MONTHLY CERTIFICATION OF ON-THE-JOB AND APPRENTICESHIP TRAINING
NAME AND FACILITY CODE OF TRAINING FACILITY

TRAINEE'S NAME AND ADDRESS

VA FILE NUMBER

PAYEE NUMBER

IMPORTANT: Read the instructions carefully. The employer should complete, date, and sign this form on or after the last day of the last month
shown in Item 1. Call 1-888-GI-BILL-1 (1-888-442-4551), if you have questions. If you use the Telecommunications Device for the Deaf (TDD)
call the Federal Relay number is 711.

INSTRUCTIONS TO CERTIFYING OFFICIAL

ITEMS 1 AND 2 - Enter the number of hours trained for each month/year shown (include any hours of related training given during working hours).
ITEM 3 - Check the appropriate box, and if training has been terminated, complete Items 4 and 5. If trainee has attained the complete job skills for their job (a
"journeyman" knowledge and skills), show this information in Item 5.
ITEMS 6A, 6B, AND 6C - Check the appropriate box. If trainee received a wage increase (or decrease) not in accordance with their training agreement, show the new
wage rate and the effective date of that wage rate (when trainee first received this wage rate).
ITEM 7 - Use Item 7, Remarks, to show any additional information concerning a change in the wage rate. Also, if the trainee is receiving additional educational allowance
for dependents, use this item to report any change in the number of the trainee's dependents. Also use Item 7 if the trainee's conduct or progress is unsatisfactory.
ITEMS 8A and 8B - Certifying Official's printed name and date. Return form to VA office address indicated on the back of form. If you have any questions, call VA toll-free
at 1-888-GI Bill (1-888-442-4551).

1. MONTH(S)/YEAR TO BE CERTIFIED

2. NUMBER OF HOURS
TRAINED FOR EACH MONTH
SHOWN IN ITEM 1

3. WAS TRAINEE ENROLLED IN AND
PURSUING THE APPROVED PROGRAM
FOR THE MONTH(S) SHOWN IN ITEM 1?

4. DATE TERMINATED

(Month, day, year)

YES
(If "No," complete Items 4 and 5)
NO
5. REASON FOR TERMINATION

6A. IS WAGE RATE IN ACCORDANCE
WITH TRAINING AGREEMENT?
YES
NO

7. REMARKS

6B. RATE

6C. EFFECTIVE DATE

(If "No," complete Items 6B and 6C)

FILE NUMBER:

I CERTIFY THAT the previous statements are true and correct to the best of my knowledge and belief.
PENALTY - Willful false reports concerning benefits payable by VA may result in fines or imprisonment or both.
8A. PRINTED NAME AND TITLE OF CERTIFYING OFFICIAL

8B. DATE SIGNED

9. SIGNATURE OF CERTIFYING OFFICIAL (Sign in ink)
PRIVACY ACT: 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., VA sends 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) VA obtains 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) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Veteran Readiness and Employment Records - VA, and
published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. While you do not have to respond, VA cannot pay the student any education benefits
until we receive the information (38 U.S.C. 3684). Your responses are 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 eligibility to benefits under this program and, if applicable, the amount due. Title 38 United States Code allows us to ask
for this information. We estimate that it will take an average of 10 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-GI-BILL-1 (1-800-442-4551) to get information on where to send
comments or suggestions about this form. (Call 711, Federal Relay, if you use the Telecommunications Device for the Deaf (TDD.))
VA FORM
XXXX

22-6553d-1

SUPERSEDES VA FORM 22-6553d-1, OCT 2019,
WHICH WILL NOT BE USED.

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Please send the completed form to the Regional Processing Office that handles claims for the state in which your
training facility is located.

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

CO

CT

DC

DE

IA

IL

IN

KS

KY

MA

MD

ME

MI

MN

MO

MT

NC

ND

NE

NH

NJ

NY

OH

PA

RI

SD

TN

VA

VT

WI

WV

WY

APO/FPO AA

FOREIGN SCHOOLS

US VIRGIN ISLANDS

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

AK

AL

AR

AZ

CA

FL

GA

HI

ID

LA

MS

NM

NV

OK

OR

PR

SC

TX

UT

WA

APO/FPO AP

VA FORM 22-6553D-1, XXXX

GUAM

PHILIPPINES

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