VA Form 22-8692a Extended Work-Study Agreement

OMB Control No. 2900-0209
Respondent Burden: 3 minutes
Expiration Date: XX/XX/20XX

EXTENDED STUDENT WORK-STUDY AGREEMENT
VA FILE NUMBER

AGREEMENT NUMBER

PRIVACY ACT INFORMATION: VA will not disclose information collected by this information collection to any source other than what has
been authorized by the Privacy Act of 1974 or Title 38 Code of Federal Regulations 1.576 for routine uses as identified in VA's system of records,
58VA21/22/28, Compensation, Pension, Education and Veteran Readiness and Employment Records - VA published in the Federal Register at
http://www.rms.oit.va.gov/SOR_Records/58VA21_22.asp. An example of a routine use allows VA to send 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) for
VA to obtain 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. Your obligation to respond is "required to obtain or retain benefits". We cannot take any action to extend your workstudy contract until we receive this information (38 U.S.C. 3485). Your responses are confidential (38 U.S.C. 5701). Any information provided by
applicants, recipients, and others may be subject to verification through computer matching programs with other agencies.
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 2900-0209, and it expires XX/XX/20XX. Public
reporting burden for this collection of information is estimated to average 3 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. 2900-0209 in any correspondence. Do
not send your completed VA Form 22-8692a to this email address.

NOTE: VA will complete the hourly rate item below with the federal minimum wage or your State minimum wage rate, whichever is
greater. If you have any questions concerning this hourly rate, contact your nearest VA office at 1-800-827-1000.

I,
(student), wish to extend my work-study agreement with the Department
of Veterans Affairs (VA). I agree to perform
hours of service for VA during the period starting
on or about
and ending no later than
.
VA agrees to pay me at the rate of $
per hour for a total extended work-study allowance of
$
. I agree to abide by the conditions set forth in my initial agreement. I also understand that I
will not receive an advance payment under this extended agreement.
NOTE: The extended agreement may not begin earlier than the starting date shown above. This form is for extended
work-study agreements only. VA Form 22-8692B, or 22-8692 (if the student requests and advance payment) must be used
for initial work-study agreements. Those forms contain the conditions of the agreement. Those conditions apply to the
extended agreement. The student and the appropriate VA official must sign both agreements.

This extended agreement is authorized under 38 U.S.C. 3485. It will become effective when signed by the
student and accepted by the VA official shown below.
SIGNATURE OF STUDENT (Sign in ink)

DATE

CURRENT MAILING ADDRESS OF STUDENT (Number and street or rural route,

city or P.O., State and ZIP Code)

VA FORM
XXX XXXX

22-8692a

SIGNATURE OF VA OFFICIAL (Sign in ink)

DATE

PERMANENT MAILING ADDRESS OF STUDENT, IF DIFFERENT (Include No.

and street or rural route, city, State and ZIP Code)

SUPERSEDES VA FORM 22-8692A, APR 2021,
WILL BE USED.