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

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

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
3. STUDENT'S NAME
SECURITY NUMBER

COMPLETE ALL ITEMS BELOW GIVING INFORMATION
ONLY FOR THE PERIOD INDICATED

4. STUDENT'S SOCIAL SECURITY NUMBER

5. ATTENDANCE
A. FROM (MM/DD/YYYY)

B. TO (MM/DD/YYYY)

STUDENT CERTIFICATION

6. DURING THE PERIOD SHOWN IN ITEM 5:
A. I AM ATTENDING FULL-TIME
B. I AM NOT ATTENDING FULL-TIME

6E. DATES OF FULL-TIME ATTENDANCE INDICATED IN ITEM 6D
FROM (MM/DD/YYYY)
TO (MM/DD/YYYY)

C. I DID NOT ATTEND
D. I ATTENDED FULL-TIME ONLY FOR THE PERIOD INDICATED IN ITEM
6E (Provide dates of full-time attendance)

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 (MM/DD/YYYY)

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)

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)

A. FROM (MM/DD/YYYY)

B. TO (MM/DD/YYYY)

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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-0394, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 15 minutes per
respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance
Officer at [email protected]. Please refer to OMB Control No. 2900-0394 in any correspondence. Do not send your completed VA Form 21P-8926 to this email address.

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
XXX XXXX

21P-8926

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

SUPERSEDES VA FORM 21-8926, MAY 2021,
WHICH WILL NOT BE USED.

13C. DATE (MM/DD/YYYY)