Form 22-1995 Request for Change of Program or Place of Training

OMB Control No. 2900-0074
Respondent Burden: 20 Minutes
Expiration Date: XX/XX/20XX

REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
PART I - IDENTIFICATION AND PERSONAL INFORMATION
1A. NAME OF APPLICANT (Last, First, Middle)

VA DATE STAMP

DO NOT WRITE IN THIS SPACE
1B. MAILING ADDRESS (Complete street address, City, State, and 9-digit ZIP Code)

1C. APPLICANT'S TELEPHONE NUMBER (Including Area Code)
HOME (include area code)

1D. VA FILE NUMBER

MOBILE (include area code)
1F. SOCIAL SECURITY OF APPLICANT (For transferability cases,

enter the veteran's social security number)

1E. APPLICANT'S E-MAIL ADDRESS (if applicable)

PART II - YOUR PROGRAM INFORMATION
2. EDUCATION BENEFIT YOU WANT TO RECEIVE (Only Select One)
A. CHAPTER 33 (Post-9/11 GI Bill)

B. CHAPTER 30 (Montgomery GI Bill - Active Duty)

D. CHAPTER 1606 (Montgomery GI Bill-

E. TRANSFER OF ENTITLEMENT PROGRAM

Selected Reserves)

C. CHAPTER 32 (Veterans Educational
Assistance Program including 903)

3. HOW WILL YOU TAKE TRAINING?
A. SCHOOL ATTENDANCE

E. TUITION ASSISTANCE TOP-UP (Active Duty Only)

B. CORRESPONDENCE

F. FLIGHT TRAINING

C. APPRENTICESHIP OR ON-THE-JOB TRAINING

G. LICENSING & CERTIFICATION TEST

D. COOPERATIVE TRAINING

H. NATIONAL ADMISSIONS EXAMS OR NATIONAL EXAMS FOR CREDIT

4A. WHAT EDUCATIONAL, PROFESSIONAL OR VOCATIONAL GOAL ARE
YOU WORKING TOWARD?

4B. WHAT IS THE NAME OF THE PROGRAM YOU ARE REQUESTING?

4C. IF CHANGING SCHOOLS, PROVIDE NAME AND COMPLETE ADDRESS
OF NEW SCHOOL OR TRAINING ESTABLISHMENT YOU ARE PLANNING
TO ATTEND (If applicable)

4D. PROVIDE NAME AND COMPLETE ADDRESS OF PREVIOUS SCHOOL OR
TRAINING ESTABLISHMENT (If only changing schools, list current school.)

4E. TELL US WHEN AND WHY YOU STOPPED TRAINING AT YOUR PRIOR SCHOOL OR ESTABLISHMENT. CONTINUE IN REMARKS, ITEM 10, OR ON A SEPARATE
SHEET IF NECESSARY (If applicable)

VA FORM
XXX XXXX

22-1995

SUPERSEDES VA FORM 22-1995, JUN 2021,
WHICH WILL NOT BE USED.

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PART III - DIRECT DEPOSIT INFORMATION
5A. DIRECT DEPOSIT (To enroll in Direct Deposit, attach a voided personal check or deposit slip to match the information provided below. Direct Deposit is not

available for Chapter 32 recipients.)

NOTE: To prevent possible delays in payment, claimants are highly encouraged to use Direct Deposit and set up an Electronic Fund Transfer (EFT.) Direct Deposit is
not available for the Post-Vietnam Era Educational Assistance Program (VEAP - Chapter 32) nor for Section 903.
START OR CHANGE EFT

5B.

STOP EFT

5C. 9 DIGIT ROUTING OR TRANSIT NUMBER

ACCOUNT TYPE:
CHECKING

ACCOUNT NUMBER:
SAVINGS

5D. NAME OF FINANCIAL INSTITUTION

PART IV - MISCELLANEOUS INFORMATION
6. INFORMATION ON DEPENDENTS (COMPLETE THIS ITEM ONLY IF YOU SERVED BEFORE JANUARY 1, 1977 (or had a delayed entry before January 2,

1978) AND YOU CURRENTLY HAVE DEPENDENTS.)
QUESTIONS

YES

NO

6A. ARE YOU CURRENTLY MARRIED?
6B. DO YOU HAVE ANY CHILDREN WHO ARE:
(1) UNDER AGE 18 OR
(2) OVER 18 BUT UNDER AGE 23, NOT MARRIED AND ATTENDING SCHOOL? OR
(3) OF ANY AGE PERMANENTLY HELPLESS FOR MENTAL OR PHYSICAL REASONS?
6C. IS EITHER YOUR FATHER OR MOTHER DEPENDENT UPON YOU FOR FINANCIAL SUPPORT?
7. RECENT PERIODS OF SERVICE (PERIODS OF ACTIVE DUTY SINCE YOUR INITIAL PERIOD OF ACTIVE DUTY.) Please complete this section for each period of your
active duty since your initial period of active duty if you have not previously reported this information. It will help VA process your claim if you attach a certified copy of
"Member 4 Copy" of your DD Form 214 for each period of active service. (Don't report Active Duty for Training.)
7A. BRANCH OF
SERVICE AND RESERVE
OR GUARD
COMPONENT SERVED
IN DURING ACTIVE
DUTY

7B. BEGINNING AND ENDING
DATES OF ACTIVE DUTY

7C. WERE YOU
INVOLUNTARILY CALLED
TO ACTIVE DUTY FOR
THIS PERIOD? (If yes send

in copies of your orders)
YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

7D. WHAT WAS THE
CHARACTER OF YOUR
DISCHARGE?

7E. IF THIS ACTIVE DUTY IS
NATIONAL GUARD DUTY, INDICATE
IF AUTHORITY IS TITLE 10
(FEDERAL) OR TITLE 32 (STATE).

(ATTACH COPIES
OF ANY ORDERS)

NOTE: DO NOT INCLUDE FULL TIME ASSIGNMENT BY A SERVICE DEPARTMENT TO A CIVILIAN SCHOOL FOR A COURSE OF EDUCATION;
ATTENDANCE AT A SERVICE ACADEMY; OR NON-CREDITABLE TIME (TIME LOST BECAUSE OF INDUSTRIAL OR AGRICULTURAL FURLOUGH,
ARREST WITHOUT ACQUITTAL, BEING AWOL, DESERTION, SENTENCE OF COURT-MARTIAL, ETC.)
8. DO YOU EXPECT TO RECEIVE EDUCATIONAL BENEFITS UNDER THE GOVERNMENT EMPLOYEE'S TRAINING ACT (GETA) FOR THE SAME COURSE(S) YOU
WILL RECEIVE VA EDUCATION BENEFITS? (Answer only if you are a Federal Government employee)
YES

NO

9. ARE YOU RECEIVING OR DO YOU ANTICIPATE RECEIVING ANY MONEY (including but not limited to Federal Tuition Assistance) FROM THE ARMED FORCES
OR PUBLIC HEALTH SERVICE FOR THE COURSE FOR WHICH YOU HAVE APPLIED TO VA FOR EDUCATION BENEFITS? IF YOU WILL RECEIVE SUCH
BENEFITS, CHECK "YES." SHOW COMPLETE DETAILS IN THE REMARKS SECTION TO INCLUDE THE SOURCE OF THE FUNDS. NOTE: IF YOU ARE APPLYING
FOR THE TUITION ASSISTANCE TOP-UP BENEFIT, CHECK "NO." (Answer only if you are on Active Duty)
YES

NO

10. REMARKS

PART V - CERTIFICATION AND SIGNATURE OF APPLICANT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief. If on active duty, I also certify that I have consulted
with an Education Service Officer (ESO) regarding my education program.
PENALTY: Willful false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the forfeiture of these or other
benefits and in criminal penalties.
11A. SIGNATURE OF APPLICANT (DO NOT PRINT)

11B. DATE SIGNED (MM/DD/YYYY)

SIGN HERE IN INK
VA FORM 22-1995, XXX XXXX

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INSTRUCTIONS & INFORMATION
When Should You Use This Form?
Use this form when:
• you're changing schools,
• you're changing your educational, professional, vocational goal,
• you left your program due to unsatisfactory attendance, progress, or conduct; and you're now reentering the same program,
• you were receiving VA education benefits as a veteran and now wish to receive benefits while on active military duty.

INSTRUCTIONS FOR SPECIFIC ITEMS ON THE FORM
Most items on this form are self-explanatory. Here is additional information on certain items.
Item #4A: Here are some examples of what we mean by "goals":
• Educational goal: GED certificate, high school diploma, bachelor's degree, master's degree, Ph.D
• Professional goal: lawyer, physician, teacher, physical therapist, medical technologist, medical records librarian, stenographer, machinist,
electronic technician, X-ray technician, radio and
• Vocational goal: TV service technician, automobile mechanic, practical nurse.
Items #5A through #5D: The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also
called direct deposit (Direct Deposit is not available for Chapter 32 recipients). To enroll in direct deposit, provide the information requested in Items
5A through 5D and attach either a voided personal check or a deposit slip to match the information in Items 5A through 5D. If you do not have a
bank account, please visit https://www.benefits.va.gov/benefits.banking.asp. This website provides information about the Veterans Benefits Banking
Program (VBBP), and a link to banks and credit unions that may fit your needs. You may also call 1-800-827-1000. If you elect not to enroll, you
must contact representatives handling waiver requests for the Department of the Treasury at 1-888-224-2950. They will encourage your participation
in EFT and address any questions or concerns you may have.
Item #6: Provide your dependents' information only if you have military service before January 1, 1977 (or delayed entry before January 2, 1978).
Item #6A: IMPORTANT: If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place
where you and/or your spouse resided at the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later date
when you become eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on when VA recognizes marriages is available at
http://www.va.gov/opa/marriage/.
If You Need Help
If you need help in completing this form, you can contact us through our home page on the Internet. Our website is: www.benefits.va.gov/gibill. Click
on the "Contact Us" tab and then the "Ask a Question" tab. Or you may call us 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. Please call 1-800-827-1000 if you want a VA counselor to help you
in planning your program.

TO FILE THIS FORM:
(A) If you have selected a school or training establishment,
Step 1: Mail the completed form to the VA Regional Processing Office in the region of that school's or establishment's physical address.
Determine the correct office from the list on page 4.
Step 2: Notify the veterans certifying official at your school or training establishment that you have applied for VA education benefits. Ask him or
her to submit your enrollment information using VA Form 22-1999, Enrollment Certification, or its electronic version.
Step 3: Wait for VA to process your application and notify you of our decision concerning your continued eligibility for educational assistance.
(B) If you have not selected a school or training establishment,
Step 1: Mail the completed form to the VA Regional Processing Office in the region of your home address. Determine the correct office from the
list on page 4.
Step 2: Wait for VA to process your application and notify you of our decision concerning your continued eligibility for educational assistance.

VA FORM 22-1995, XXX XXXX

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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

FOREIGN
SCHOOLS

APO/FPO AA

U.S. VIRGIN ISLANDS

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

LA

AL

ID

AR

HI

AZ

GA

CA

FL

MS

WA

NM

UT

NV

TX

OK

SC

OR

PR

APO/FPO AP

GUAM

PHILIPPINES

AMERICAN SAMOA

MARIANA ISLANDS

REQUEST TO OPT OUT OF INFORMATION SHARING WITH EDUCATIONAL INSTITUTIONS:
The Harry W. Colmery Veterans Educational Assistance Act of 2017 (Public Law 115-48), also known as the "Forever GI Bill," requires the Department
of Veterans Affairs (VA) to make available to educational institutions information about the amount of educational assistance to which a Veteran or
other eligible individual is entitled. If you're eligible for the Post-9/11 GI Bill (Chapter 33), Montgomery GI Bill - Active Duty (Chapter 30),
Montgomery GI Bill -Selected Reserve, (Chapter 1606), or the Survivors' and Dependents' Educational Assistance Program (DEA) (Chapter 35), you
may elect to “opt-out” of these disclosures and have VA withhold this information instead. To request an opt-out, or for information about how to optout, please refer to our website at va.gov, or click https://www.va.gov/find-forms/, to complete the Request to Opt-Out of Information Sharing with
Educational Institutions, VA Form 22-0993.
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, Code of Federal Regulations, section 1.526 for routine uses (e.g. 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) for the VA to
obtain further information as may be necessary from the school for the 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 Services - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain education benefits. The
requested information is considered relevant and necessary to determine the maximum benefits under the law. While you do not have to respond, VA
cannot process your claim for education assistance unless the information is furnished as required by existing law (38 U.S.C. 3471). The responses you
submit are considered 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 2900-0074, and it expires XX/XX/20XX. Public reporting
burden for this collection of information is estimated to average 20 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. 2900-0074 in any correspondence. Do not send your
completed VA Form XXX to this email address.

VA FORM 22-1995, XXX XXXX

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