Form 21-674 Request for Approval of School Attendance

(If other than full time high school or college course) COURSE (Month day year) GOVERNMENT? PER WEEK VA FORM 21 674 FEB 2012 (1 A DATE SCHOOL ATTENDANCE TERMINATED (Month day year) Enter 2 digit month 2 digit day and 4 digit year ) (1 ADDRESS OF V A OFFICE) (10B SUBJECT FOR WHICH STUDENT IS ENROLLED (10C NUMBER OF (10D HOURS PER WEEK) (11B NAME AND ADDRESS OF SCHOOL ATTENDED LAST TERM) (11C NUMBER OF SESSIONS (11D HOURS PER WEEK) (11E BEGINNING DATE OF LAST TERM Enter 2 digit month 2 digit day and 4 digit year ) (11F ENDING DATE OF LAST TERM Enter 2 digit month 2 digit day and 4 digit year ) (14 REMARKS) (15 A SIGNATURE This is a protected field ) (15B DAYTIME PHONE NUMBER (Include Area Code)) (15C EVENING PHONE NUMBER (Include Area Code)) (16 RELATIONSHIP TO STUDENT) (17 DATE Enter 2 digit month 2 digit day and 4 digit year ) (2 A BEGINNING DATE OF THE NEXT REGULAR TERM FOLLOWING (2A FIRST NAME MIDDLE INITIAL LAST NAME OF VETERAN (Type or Print) ) (2B E MAIL ADDRESS OF VETERAN (If applicable)) (2B OFFICIAL ENDING DATE OF REGULAR TERM (Month day year)Enter 2 digit month 2 digit day and 4 digit year ) (3 V A FILE NUMBER) (4 A FIRST NAME MIDDLE INITIAL LAST NAME OF STUDENT (Veteran's child attending school) (Type or print)) (4B STUDENT'S SOCIAL SECURITY NUMBER Enter 9 digit social security number ) (4D DATE OTHER FEDERAL BENEFITS BEGAN (Month day year)) (5 A DATE OF BIRTH Enter 2 digit month 2 digit day and 4 digit year ) (5A DATE OF MARRIAGE Enter 2 digit month 2 digit day and 4 digit year ) (5B MARRIED NAME (If female student)) (5C ADDRESS OF STUDENT (Number and Street or Rural Route City or P O State and ZIP Code)) (5C DATE OF MARRIAGE Enter 2 digit month 2 digit day and 4 digit year ) (6 ADDRESS OF STUDENT (Number and Street or Rural Route City or P O State and Zip Code)) (6 REMARKS) (7 NAME OF SCHOOL) (7B AGENCY NAME) (7C DATE PAYMENTS BEGAN Enter 2 digit month 2 digit day and 4 digit year ) (8 DATE Enter 2 digit month 2 digit day and 4 digit year ) (8A NAME AND ADDRESS OF SCHOOL FOR WHICH APPROVAL IS REQUESTED) (8B NAME OR TYPE OF COURSE OF EDUCATION OR TRAINING) (9 SIGNATURE OF CLAIMANT GUARDIAN OR CUSTODIAN This is a protected field ) (9A OFFICIAL BEGINNING DATE OF REGULAR TERM OR COURSE (Month day year)) (9C EXPECTED DATE OF GRADUATION (A SAVINGS (Including cash)) (ALL OTHER INCOME (Interest dividends etc ) EXPECTED) (ALL OTHER INCOME (Interest dividends etc ) RECEIVED) (ANNUAL SOCIAL SECURITY EXPECTED) (ANNUAL SOCIAL SECURITY RECIEVED) (B DATE STUDENT STARTED OR EXPECTS TO START COURSE (Month day year)) (B SECURITIES BONDS ETC ) (C REAL ESTATE (Not your home)) (D ALL OTHER ASSETS) (D TRANSFER TO ANOTHER INSTITUTION (Specify name and address of other institution if known)) (DropDownList1) VA FILE COPY 1 (E OTHER (Please explain)) (E TOTAL OF ABOVE) (EARNINGS FROM ALL EMPLOYMENT EXPECTED) (EARNINGS FROM ALL EMPLOYMENT RECIEVED) (If "No " complete Item 2B) (If "No " complete Items (If "Yes " complete Item 2A) (If "Yes " complete Items 7B and 7C If "No " skip to Item 8A) (If other than full time high school or college course)) (Include Area Code) (Including cash) (Interest dividends etc ) (Month day year) (Month day year) Enter 2 digit month 2 digit day and 4 digit year ) (Not your home) (OTHER ANNUITIES EXPECTED) (OTHER ANNUITIES RECIEVED) (Report for year following (REPORT FOR YEAR IN WHICH SCHOOL (Specify name and address of other institution if known) (Unscheduled Termination or Change) 1 ADDRESS OF VA OFFICE 10A IS STUDENT EN 10B 10C and 10D) 10B SUBJECT FOR WHICH STUDENT IS ENROLLED 10C NUMBER OF 10D HOURS 11A WAS STUDENT ATTENDING ANY SCHOOL AT END OF 11B NAME AND ADDRESS OF SCHOOL ATTENDED LAST TERM 11C NO OF SESSIONS 11D HOURS PER WEEK 11E BEGINNING DATE OF LAST TERM 11F ENDING DATE OF LAST TERM 12 REPORT OF INCOME BY CALENDAR YEAR(IMPORTANT Do NOT report VA benefits) 13 VALUE OF ESTATE 14 REMARKS 15A SIGNATURE 15B DAYTIME PHONE NO 15C EVENING PHONE NO 16 RELATIONSHIP TO STUDENT 17 DATE 18 but under 23 and attending school The veteran's child should complete the form only if he or she has reached the 1B IS THIS THE OFFICIAL ENDING DATE OF REGULAR TERM FOR SUCH COURSE? 2A FIRST NAME MIDDLE INITIAL LAST NAME OF VETERAN (Type or Print) 2B E Mail ADDRESS OF VETERAN (If 2B OFFICIAL ENDING DATE OF REGULAR TERM (Month day year) 3 REASON FOR TERMINATION OF ATTENDANCEA FAILURE TO START COURSE OF TRAININGB FAILURE TO RESUME COURSEC COMPLETION OF COURSED TRANSFER TO ANOTHER INSTITUTION 3 VA FILE NUMBER 4 REASON FOR TERMINATION DUE TO CHANGE IN STATUSB RECEIPT OF FEDERAL EMPLOYEES' COMPENSATION ACT (FECA) 4A FIRST NAME MIDDLE INITIAL LAST NAME OF STUDENT (Veteran's child attending school) (Type or print) 4B STUDENT'S SOCIAL SECURITY NUMBER 5A DATE OF BIRTH 5B HAS STUDENT EVER MARRIED? 5B MARRIED NAME (If female student) 5C ADDRESS OF STUDENT(No and street or rural route city or P O State and ZIP Code) 5C DATE OF MARRIAGE 6 ADDRESS OF STUDENT (Number and street or rural route city 6 REMARKS 7 NAME OF SCHOOL 7A IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID BY 7B AGENCY NAME 7C DATE PAYMENTS BEGAN (Month day year) 8 DATE 8A NAME AND ADDRESS OF SCHOOL FOR WHICH APPROVAL IS REQUESTED 8B NAME OR TYPE OF COURSE OF EDUCATION OR TRAINING 9 SIGNATURE OF CLAIMANT GUARDIAN OR CUSTODIAN 9A OFFICIAL BEGINNING DATE OF REGULAR TERM OR 9B DATE STUDENT STARTED OR EXPECTS TO START 9C EXPECTED DATE OF GRADUATION A RECEIPT OF VA DEPENDENT'S EDUCATIONAL ASSISTANCE (DEA) BENEFITS4D DATE OTHER FEDERAL BENEFITS BEGAN (Month day year) A SAVINGS A SOURCE Academy Bureau of Indian Affairs etc ) is paying the student's tuition Do not answer "Yes" simply because Social Academy U S Merchant Marine Academy Bureau of Indian Affairs etc ) with additional compensation payments based on the student's school attendance is considered a age 18 and 23 and attending school (38 U S C 104(a)) Title 38 United States Code allows us to ask for this information age of majority and is or will be entitled to receive direct payment of VA benefits NOTE: The age of majority is All claimants must complete this part Answer "Yes" to Item 7A only if Federal Employee's Compensation VA ALL EMPLOYMENT ALL OTHER INCOME and your dependents' SSN account information is mandatory Applicants are required to provide their SSN and the SSN of ANNUAL SOCIAL ANNUITIES any dependents for whom benefits are claimed under Title 38 U S C 5101(c)(1) VA will not deny an individual benefits applicable) apply Make sure to write the veteran's name and VA claim number on any attachments to this form are amounts paid by the student for his or her course of post secondary education or vocational rehabilitation including attendance or marriage attendance receipt of Dependents Educational Assistance or marriage prior to completion of the course I understand that continued entitlement to school attendance may be authorized under the Privacy Act of 1974 or Title 38 Code of Federal Regulations 1 576 for routine uses (i e civil or B RECEIVED B SECURITIES BONDS based on information I have furnished on this form Any benefits allowed due to this certification will be discontinued if the student marries receives VA Dependents before you take out deductions for taxes insurance etc block must be completed If you do not receive income from a particular source write "0" or "none" in the space Bureau of Indian Affairs Job Corp etc ) C EXPECTED C REAL ESTATE C RECEIPT OF OTHER FEDERAL BENEFITS (Such as U S Service Academy U S Merchant Marine Academy C/CSS COMPENSATION ACT OR ANY OTHERAGENCY OR PROGRAM OF THE UNITED STATES complete if the student is a dependent on a veteran's or surviving spouse's award Complete this part only if the benefit being claimed or received is disability pension or death pension Each income criminal law enforcement congressional communications epidemiological or research studies the collection of money D ALL OTHER ASSETS Department of Veterans Affairs Dependents Educational Assistance (DEA) or another Federal Agency (U S Service Academy U S Merchant Marine determined by State law; it is age 18 in most states duplication of benefits and is prohibited E OTHER(Please explain) E TOTAL OF ABOVE earned income of the student Report the total amount(s) paid and dates of payment in Item 14 "Remarks " EARNINGS FROM Education Assistance (DEA) benefits leaves school or passes away FEB 201221 674WILL BE USED for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect form VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed You are Government or marries prior to completion of the course his or her right Otherwise the veteran surviving spouse guardian or custodian will sign and also enter his or her How do I complete VA Form 21 674? I AGREE to notify the Department of Veterans Affairs immediately of any changes in this course of education transfer to another school discontinuance of school I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief I CERTIFY THAT the information given above is true and correct to the best of my knowledge and belief and request approval of the course of education or training shown above if the VA benefit payable will be death pension and there is no surviving spouse entitled to death pension Do not IMPORTANT Be sure to read the Instructions on the reverse of Copy 1 before completing this form The form should be completed in duplicate and signed in Part III Improved Pension: Complete this part showing the student's income Educational or vocational rehabilitation expenses information on where to send comments or suggestions about this form Information submitted is subject to verification through computer matching programs with other agencies INSTRUCTIONS INSTRUCTIONS: The appropriate items below should be completed and the form returned to the Department of Veterans Affairs if knowing it to be false LAST SCHOOL TERM? located on the OMB Internet Page at www reginfo gov/public/do/PRAMain If desired you can call 1 800 827 1000 to get NO(If "Yes " complete Item 5C) NO(If "Yes " complete Items 11B thru 11F) not required to respond to a collection of information if this number is not displayed Valid OMB control numbers can be NOTE: Read the instructions carefully before completing this form NOTE: This part will be completed by the student only if he or she has attained majority and is claiming benefits in his or her own right Otherwise the veteran surviving OMB Approved No 2900 0049 OR COLLEGE COURSE? or P O State and Zip Code) OTHER owed to the United States litigation in which the United States is a party or has an interest the administration of VA PART I PART I NOTICE OF TERMINATION OF SCHOOL ATTENDANCE1A DATE SCHOOL ATTENDANCE TERMINATED (Month day year) PART I TO BE COMPLETED BY CLAIMANT (Also sign certification in Part III) PART II PART II NOTICE THAT STUDENT MARRIED5A DATE OF MARRIAGE PART II STUDENT'S INCOME AND NET WORTH (See instructions on reverse for when required) PART III PART III CERTIFICATION AND AGREEMENT TO BE SIGNED BY CLAIMANT PENALTY The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statements or evidence of a material fact PENALTY: The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a material fact knowing it to be false PER WEEK PER WEEK) Print all answers clearly For additional space attach a separate sheet indicating the item number to which the answers prior to January 1 1975 and still in effect The responses you submit are considered confidential (38 U S C 5701) Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been programs and delivery of VA benefits verification of identity and status and personnel administration) as identified in the provided Do not leave the space blank VA will interpret a blank space as "0" or "None" Report the gross amounts Receipt by the student of VA Dependents Educational Assistance (DEA) the Federal Employee's Compensation Act or benefit from another Federal Agency (U S Service Records VA and published in the Federal Register Your obligation to repond is required to obtain or retain benefits the relationship to the student in Item 16 REQUEST FOR APPROVAL OF SCHOOL ATTENDANCE requested information is considered relevant and necessary to determine maximum benefits under the law Giving us your Respondent Burden: 15 minutes Respondent Burden: We need this information to determine entitlement to benefits for a veteran's child who is between reverse School Attendance Report to report to VA any change in the child's status such as termination of school ROLLED IN A FULL SCHOOL ATTENDANCE REPORT Section 306 or Old Law Pension (entitlement to pension established before January 1 1979): Complete this part only SECURITY Security benefits have been awarded based on the student's continuing school attendance SESSIONS PER WEEK SESSIONS PER WEEK) shown mail or take it to the nearest VA regional office Keep Claimant's Copy 2 for your own records and use the spouse guardian or custodian will sign and also enter his or her relationship to the student Submit the original copy (VA File Copy 1) of the completed form to the VA office shown in Item 1 If no address is TERM BEGINS SEE ITEM 9 ABOVE) that shown in Column B) THE DATE STUDENT DISCONTINUED SCHOOL (Month day year) THE DATE STUDENT DISCONTINUED SCHOOL (Month day year) Enter 2 digit month 2 digit day and 4 digit year ) the student whose enrollment is recorded on the face of this form discontinues the approved course of education or training receives This part will be completed by the student only if he or she has reached the age of majority and is claiming benefits in TIME HIGH SCHOOL tuition fees and materials If any of these expenses are paid by the student the expenses may be deducted from the VA Dependents' Educational Assistance (DEA) benefits enters an educational institution entirely supported by the Federal VA DEPENDENTS EDUCATIONAL ASSISTANCE (DEA) THE FEDERAL EMPLOYEE'S VA FORM 21 674 FEB 2012 VA Form 21 674 should be completed by the person receiving or claiming benefits for a veteran's child who is at least VA FORM EXISTING STOCKS OF VA FORM 21 674 SEP 2008 VA system of records 58VA21/22/28 Compensation Pension Education and Vocational Rehabilitation and Employment We estimate that you will need an average of 15 minutes to review the instructions find the information and complete this YESNO YESNO2A BEGINNING DATE OF THE NEXT REGULAR TERM FOLLOWING