Form VBA-22-0803 Application for Reimbursement of Licensing or Certificat

OMB Approved No. 2900-0695
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

APPLICATION FOR REIMBURSEMENT OF LICENSING OR
CERTIFICATION TEST FEES

IMPORTANT: Complete this application to apply for reimbursement of licensing or certification test fees. You must apply separately for VA
education benefits if you have not already done so. To apply, please complete the Application for VA Education Benefits using VA Form 22-1990.
If found that you qualify for VA benefits, you can receive reimbursement of a licensing or certification test fee under one of the following programs.
Please choose one.

Montgomery GI Bill - Active Duty Educational Assistance Program (MGIB) (Chapter 30)
Post-Vietnam Era Veterans Educational Assistance Program (VEAP) (Chapter 32)
Post-9/11 GI Bill (Chapter 33)
Survivors' and Dependents' Educational Assistance Program (DEA) (Chapter 35)
Montgomery GI Bill - Selected Reserve Program (MGIB-SR) (Chapter 1606)
(See the reverse for Information and Instructions for completing this form.)

PART I - IDENTIFICATION INFORMATION

1. NAME OF APPLICANT (First, Middle Initial, Last Name)

2. MAILING ADDRESS OF APPLICANT (Number and street or rural route, city or P. O., State and ZIP Code)

4. VA FILE NUMBER (For chapter 35, enter the veteran's file number. Be
sure to include the suffix indicator).

3. EMAIL ADDRESS

5. TELEPHONE NUMBER (Include Area Code)
MOBILE
HOME

6. VA EDUCATION INFORMATION

A. HAVE YOU PREVIOUSLY APPLIED FOR VA EDUCATION BENEFITS?
YES

NO

(If "No," you should complete an application for education benefits as indicated in the "IMPORTANT" paragraph information above).

7. NAME OF TEST (Use this application for one test only)

PART II - TEST INFORMATION

8. COMPLETE NAME AND MAILING ADDRESS OF ORGANIZATION
ISSUING LICENSE OR CERTIFICATION (Please specify who will issue the
license or certification).

9. DATE TEST TAKEN AND TEST RESULTS (See the Instructions for this
item for information and evidence you must specify or attach to this
application) (If more space is needed, use Item 11 Remarks).

10. COST OF TEST INCLUDING MANDATORY FEES (Please attach
test fee receipt or submit the receipt with form) (If more space is needed,
use Item 11 Remarks).
11. REMARKS

I hereby authorize the release of my test information to the Department of Veterans Affairs (VA).
13. DATE SIGNED (MM/DD/YYYY)

12. SIGNATURE OF APPLICANT

IMPORTANT: To apply for reimbursement of a licensing or certification test fee, please return this form to the VA office which handles your area.
See the addresses on page 2 of this form. Include a copy of your test results.
VA FORM
XXX XXXX

22-0803

SUPERSEDES VA FORM 22-0803, AUG 2020,
WHICH WILL NOT BE USED.

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INFORMATION

(The items that are considered self-explanatory are not included in these instructions)
ITEM 3. If you (or the veteran or service member) were previously assigned an 8-digit file number, enter this number.
ITEM 6. If you have not previously applied for VA education benefits, go to www.benefits.va.gov/gibill/, and click on "Apply for Benefits". See
the top of this form for the education benefits that permit reimbursement of Licensing or Certification tests.
ITEM 7. Write the complete name of the test.
ITEM 8. Write the complete name and complete mailing address (including ZIP Code) of the organization issuing the license or certificate (not
necessarily the organization that administered the test).
ITEM 9. Show the date you took the test and attach a copy of your test results. (If you do not have any test results but have a copy of your license
or certification and a payment receipt for your test, attach these documents.) Reimbursement of the test fee can't be paid until this information is
received. Please provide this information for the test you want to receive reimbursement.
ITEM 10. Enter the cost of the test you took, including any required fees. (We can only reimburse you for required test fees.) We
have no authority to reimburse you for any optional costs related to the test process. Test fees that VA will reimburse include
"registration fees," fees for specialized tests, and administrative fees such as a proctoring fee. Fees that VA has no authority to
reimburse include fees to take pre-tests (such as Kaplan exams), fees to receive scores quickly, or other costs or fees for optional items that are not
required to take an approved test.
ITEMS 12 and 13. Sign and date the form.
Additional Information: You may provide additional information that you think will help VA process your claim. Attach additional sheets of paper
to this application if necessary. Additional information should be properly labeled (such as: Item 1, if the additional information supports Item 1 on
the form).
MORE HELP: If you need help in completing this application, call VA TOLL-FREE at 1-888-GI-BILL-1 (1-888-442-4551). If you use the
Telecommunications Device for the Deaf (TDD), the Federal Relay number is 711. You can also get education assistance at our education Internet
site: https://www.va.gov.
HOW TO FILE YOUR CLAIM: Send the completed application to the Regional Processing Office for your region. The addresses for your
region are listed in the chart below.
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

GUAM

PHILIPPINES

AMERICAN SAMOA

MARIANA ISLANDS

PRIVACY ACT INFORMATION: 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, published in the Federal Register. Your
obligation to respond is required to obtain or retain benefits (licensing and certification test reimbursement). While you do not have to respond, VA cannot reimburse you any licensing and certification test
fees until we receive this information (38 U.S.C. 3452(b) and 3501(a)). 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 your eligibility for reimbursement of licensing and certification test fees. We cannot pay you any education benefits for this
reimbursement until we receive this information (38 U.S.C. 5101). 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 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. If you are hearing impaired, call 1-888-829-4833.

VA FORM 22-0803, XXX XXXX

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