22-1995

1C. APPLICANT'S TELEPHONE NUMBER (Including Area Code)

3. HOW WILL YOU TAKE TRAINING?

4C. IF CHANGING SCHOOLS, PROVIDE NAME AND COMPLETE ADDRESS

OF NEW SCHOOL OR TRAINING ESTABLISHMENT YOU ARE PLANNING

TO ATTEND

(If applicable)

PART I - IDENTIFICATION AND PERSONAL INFORMATION

OMB Control No. 2900-0074

Respondent Burden: 20 Minutes

Expiration Date: 08/31/2024

REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING

1B. MAILING ADDRESS (Complete street address, City, State, and 9-digit ZIP Code)

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

4D. PROVIDE NAME AND COMPLETE ADDRESS OF PREVIOUS SCHOOL OR

TRAINING ESTABLISHMENT (If only changing schools, list current school)

4A. WHAT EDUCATIONAL, PROFESSIONAL OR VOCATIONAL GOAL ARE

YOU WORKING TOWARD?

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

PART II - YOUR PROGRAM INFORMATION

1A. NAME OF APPLICANT (Last, First, Middle)

NATIONAL ADMISSIONS EXAMS OR

NATIONAL EXAMS FOR CREDIT

CHAPTER 33

(Post-9/11 GI BILL)

CHAPTER 30 (Montgomery GI Bill -

Active Duty)

VA FORM

JUL 2021

22-1995

SUPERSEDES VA FORM 22-1995, JUL 2020,

WHICH WILL NOT BE USED.

LICENSING & CERTIFICATION TEST

TRANSFER OF ENTITLEMENT PROGRAM

1E. APPLICANT'S E-MAIL ADDRESS

(if applicable)

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)

1D. VA FILE NUMBER

MOBILE

(include area code)

1F. SOCIAL SECURITY NUMBER OF APPLICANT (For transferability cases,

enter the veteran's social security number)

HOME (include area code)

FLIGHT TRAINING

CHAPTER 1606

(Montgomery GI Bill-

Selected Reserve)

TUITION ASSISTANCE TOP-UP

(Active Duty Only)

2. EDUCATION BENEFIT YOU WANT TO RECEIVE (Only Select One)

E.CORRESPONDENCEB.

SCHOOL ATTENDANCE

APPRENTICESHIP OR ON-THE-JOB

TRAINING

A. COOPERATIVE TRAININGD.

Page 1

CHAPTER 32 (Veterans Educational Assistance

Program including section 903)

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.)

6C. IS EITHER YOUR FATHER OR MOTHER DEPENDENT UPON YOU FOR FINANCIAL SUPPORT?

PART IV - MISCELLANEOUS INFORMATION

NOQUESTIONS YES

6A. ARE YOU CURRENTLY MARRIED?

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.)

6B. DO YOU HAVE ANY CHILDREN WHO ARE:

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)

7A. BRANCH OF SERVICE

AND RESERVE OR GUARD

COMPONENT SERVED IN

DURING ACTIVE DUTY

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)

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)

7D. WHAT WAS THE CHARACTER

OF YOUR DISCHARGE?

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.)

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

YES NO

10. REMARKS

YES NO

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.

SIGN HERE IN INK

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.

11A. SIGNATURE OF APPLICANT (DO NOT PRINT) 11B. DATE SIGNED

(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?

VA FORM 22-1995, JUL 2021

Page 2

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. See Instructions, Item 5 for additional Direct Deposit

Information.)

PART III - DIRECT DEPOSIT INFORMATION

5C. 9 DIGIT ROUTING OR TRANSIT NUMBER ACCOUNT NUMBER

5B. START OR CHANGE EFT STOP EFT

ACCOUNT TYPE

SAVINGS

CHECKING

5D. NAME OF FINANCIAL INSTITUTION

When Should You Use This Form?

Use this form when:

• you are changing schools,

• you are changing your educational, professional, vocational goal,

• you left your program due to unsatisfactory attendance, progress, or conduct; and you are 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/.

TO FILE THIS FORM:

(A) If you have selected a school or training establishment,

Step1: 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.

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.

INSTRUCTIONS & INFORMATION

VA FORM 22-1995, JUL 2021

Page 3

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: We need this information to determine your continued eligibility to VA education benefits (38 U.S.C. 3471). Title 38,

United States Code, allows us to ask for this information. We estimate that you will need an average of 20 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 (1-888-442-4551) to get information on where

to send comments or suggestions about this form.

VA FORM 22-1995, JUL 2021

Page 4

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

U.S. VIRGIN ISLANDS

SERVES THE FOLLOWING STATES

Eastern Region:

VA Regional Office

P. O. Box 4616

Buffalo, NY 14240-4616

AK AL AR AZ CA FL GA HI ID LA

MS NM NV OK OR PR SC TX UT WA

SERVES THE FOLLOWING STATES

Western Region:

VA Regional Office

P.O. Box 8888

Muskogee, OK 74402-8888

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 opt-

out, 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.

REQUEST TO OPT OUT OF INFORMATION SHARING WITH EDUCATIONAL INSTITUTIONS:

APO/FPO AP GUAM PHILIPPINES AMERICAN SAMOA MARIANA ISLANDS