Form 22-5490 Dependents' Application for VA Education Benefits (Under Provisions of chapters 33 and 35, of title 38, U.S.C.)

(1) The spouse or child of a veteran who is permanently and totally disabled as a result of a service connected disability (A) If you have selected a school or training establishment: INTERNET VERSION AVAILABLE You may complete and submit this application on line at www gibill va gov Click on "GI Bill: Post 9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship (Fry Scholarship) Survivors' and Dependents' Educational Assistance Program (DEA) (chapter 35 of title 38 U S Code) "Correspondence " Only spouses and surviving spouses eligible for the Survivors' and Dependents' Educational Assistance program "Flight Training " You must already have a private pilot's license If you are taking an Airline Transport Pilot course you must have a "Licensing or Certification Test " A licensing test is a test offered by a state local or federal agency that is required by law to practice "National Admission Exam or National Exam for Credit " Individuals eligible to receive benefits under the Survivors' and Dependents' ( 29 SOCIAL SECURITY NUMBER OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS Enter 9 digit social security number ) (1 888 442 4551) or if you use the Telecommunications Device for the Deaf (TDD) the Federal Relay number is 711 (1 SOCIAL SECURITY NUMBER Enter 9 digit social security number ) (10 NAME OF INDIVIDUAL ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (FIRST MIDDLE LAST) ) (11 SOCIAL SECURITY NUMBER OR VA FILE NUMBER ) (12 BRANCH OF SERVICE) (19 NAME AND ADDRESS OF SCHOOL OR TRAINING FACILITY (Number and street or rural route city or P O State and ZIP Code) ) (2) The spouse or child of an individual on active duty who has been listed as missing in action captured in line of duty (20 SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE IF KNOWN (For example Bachelor of Arts in Accounting Welding Certificate Police Officer ) ) (28 NAME OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS (First Middle Last) ) (3) The surviving spouse or child of a veteran who died of a service connected disability or who dies while a (34D NUMBER OF SEMESTER QUARTER OR CLOCK HOURS COMPLETED ) (34D NUMBER OF SEMESTER QUARTER OR CLOCK HOURS COMPLETED ) (34E DEGREE DIPLOMA OR CERTIFICATE RECEIVED ) (34E DEGREE DIPLOMA OR CERTIFICATE RECEIVED ) (34F MAJOR FIELD OR COURSE OF STUDY ) (34F MAJOR FIELD OR COURSE OF STUDY ) (36B SOURCE OF EDUCATIONAL ASSISTANCE FROM GOVERNMENT (37 REMARKS (If more space is needed please attach a separate sheet of paper Be sure to include name and social security number on each sheet) ) (39A SIGNATURE OF APPLICANT (DO NOT PRINT) This is a protected field ) (4 NAME (FIRST MIDDLE LAST) ) (4) The spouse or child of an individual on active duty for which the evidence shows that the individual is hospitalized (5 CURRENT MAILING ADDRESS (Number and street or rural route city or P O State and ZIP Code) ) (7 E MAIL ADDRESS (If applicable) ) (A EMPLOYER) (A EMPLOYER) (A NAME) (ACCOUNT NUMBER) (B ADDRESS) (B JOB TITLE) (B JOB TITLE) (B) If you have not selected a school or training establishment: (C BRANCH OF SERVICE OR RESERVE OR GUARD COMPONENT) (C BRANCH OF SERVICE OR RESERVE OR GUARD COMPONENT) (C NUMBER OF MONTHS EMPLOYED) (C NUMBER OF MONTHS EMPLOYED) (C TELEPHONE NUMBER (Include Area Code) ) (chapter 33 of title 38 U S Code) (City and State) (D CHARACTER OF DISCHARGE) (D CHARACTER OF DISCHARGE) (D LICENSE OR RATING) (D LICENSE OR RATING) (D VETERANS EDUCATION ASSISTANCE BASED ON YOUR OWN SERVICE SPECIFY BENEFIT(S):) (DATE SIGNED) (DAY 1 of 2 ) (DAY 1 of 2 ) (DAY 2 of 2 ) (DAY 2 of 2 ) (ENTER COLLEGE DATES OF TRAINING FROM) (ENTER DATE ENTERED ACTIVE DUTY (Line 1 of 3)) (ENTER DATE ENTERED ACTIVE DUTY (Line 2 of 3)) (ENTER DATE ENTERED ACTIVE DUTY (Line 3 of 3)) (ENTER DATE FOR ITEM CHECKED FOR NUMBER 32 ) (ENTER DATE OF BIRTH) (ENTER DATE OF BIRTH) (ENTER DATE OF DEATH MISSING IN ACTION OR P O W ) (ENTER DATE SEPARATED FROM ACTIVE DUTY (Line 1 of 3)) (ENTER DATE SEPARATED FROM ACTIVE DUTY (Line 2 of 3)) (ENTER DATE SEPARATED FROM ACTIVE DUTY (Line 3 of 3)) (ENTER HIGH SCHOOL DATES OF TRAINING TO ) (ENTER OTHER DATES OF TRAINING FROM) (ENTER VOCATIONAL OR TRADE DATES OF TRAINING FROM) (ENTER VOCATIONAL OR TRADE DATES OF TRAINING TO) (For VA Use Only) (Fry Scholarship Applicants Skip to Part V) (G OTHER (Specify benefit(s)) (HIGH SCHOOL DATES OF TRAINING FROM) (MONTH 1 of 2 ) (MONTH 1 of 2 ) (MONTH 2 of 2 ) (MONTH 2 of 2 ) (Name and Location of College (City and State)) (Name and Location of High School (City and State)) (Name and Location of Other (City and State)) (Name and Location of Vocational or Trade (City and State)) (Note: Chapter 35 benefits are not payable while an eligible person is on active duty) (OTHER (Specify)) (Please detach at perforation and retain this information for future reference) (PRIMARY TELEPHONE NUMBER (Including Area Code) ) (ROUTING OR TRANSIT NUMBER) (SECONDARY TELEPHONE NUMBER (Including Area Code) ) (SOCIAL SECURITY NUMBER 1 of 9 ) (SOCIAL SECURITY NUMBER 2 of 9 ) (SOCIAL SECURITY NUMBER 3 of 9 ) (SOCIAL SECURITY NUMBER 4 of 9 ) (SOCIAL SECURITY NUMBER 5 of 9 ) (SOCIAL SECURITY NUMBER 6 of 9 ) (SOCIAL SECURITY NUMBER 7 of 9 ) (SOCIAL SECURITY NUMBER 8 of 9 ) (SOCIAL SECURITY NUMBER 9 of 9 ) (Specify) (VA FORM 22 5490) (YEAR 1 of 4 ) (YEAR 1 of 4 ) (YEAR 2 of 4 ) (YEAR 2 of 4 ) (YEAR 3 of 4 ) (YEAR 3 of 4 ) (YEAR 4 of 4 ) (YEAR 4 of 4 ) 11 SOCIAL SECURITY NUMBER OR VA FILE NUMBER 12 BRANCH OF SERVICE 13 DATE OF BIRTH 14 DATE OF DEATH OR DATE LISTED AS 15 IS QUALIFYING INDIVIDUAL CURRENTLY ON ACTIVE DUTY? 18A & 18B Types of education or training programs are self explanatory except for the following 18A Select the benefit for which you are applying 18A TYPE OF BENEFIT VA DATE STAMP 18B To qualify for the Fry Scholarship you must be the child of an individual who after September 10 2001 died in the line of duty 18B TYPE OF TRAINING 19 NAME AND ADDRESS OF SCHOOL OR TRAINING FACILITY (Number and street or rural route city or P O State and ZIP Code) 2 SEX OF APPLICANT 20 SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE IF KNOWN (e g Bachelor of Arts in Accounting Welding Certificate Police Officer ) 21 DATE YOU WILL BEGIN SCHOOL OR TRAINING 22 1990 To apply for vocational rehabilitation benefits use VA Form 28 1900 22 5490 23 ARE YOU A HANDICAPPED CHILD (14 YEARS OR OLDER) SPOUSE OR 24 ARE YOU A HANDICAPPED CHILD SPOUSE OR SURVIVING 25 IF YOU ARE THE SURVIVING SPOUSE OF A DECEASED VETERAN HAVE YOU REMARRIED SINCE HIS OR HER DEATH? 26 I CERTIFY that I understand the effects of an election to receive DEA benefits and I elect to receive such benefits on the following date: 27 PRIOR TO THIS APPLICATION HAVE YOU EVER APPLIED FOR OR RECEIVED ANY OF THE FOLLOWING VA BENEFITS? (Check all appropriate boxes) 28 NAME OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS (First Middle Last) 29 SOCIAL SECURITY NUMBER OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS 30 HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES?(If "No " skip to Part VII) 31 INFORMATION ABOUT YOUR PERIOD(S) OF ACTIVE DUTYA DATE ENTERED ACTIVE DUTYB DATE SEPARATED FROM 32 CHECK THE APPROPRIATE BOX AND ENTER THE DATE IN ITEM 33GRADUATED FROM HIGH SCHOOLEXPECT TO GRADUATE FROM HIGH SCHOOLNEVER ATTENDED HIGH SCHOOLAWARDED GED 33 DATE 34C DATES OF TRAINING34D NUMBER OF 34E DEGREE 34F MAJOR FIELD OR 36A DO YOU EXPECT TO RECEIVE FUNDS FROM YOUR AGENCY OR 36B SOURCE OF EDUCATIONAL ASSISTANCE FROM GOVERNMENT 37 REMARKS (If more space is needed please attach a separate sheet of paper Be sure to include name and social security number on each sheet) 38 THE MOST CURRENT INFORMATION ON VA EDUCATION BENEFITS IS AVAILABLE ONLINE AT www gibill va gov IF YOU WOULD LIKE A COPY OF THE VA 39A SIGNATURE OFAPPLICANT (DO NOT PRINT) 39B DATE SIGNED 4 NAME (FIRST MIDDLE LAST) 5 CURRENT MAILING ADDRESS (Number and street or rural route city or P O State and ZIP Code) 6 TELEPHONE NUMBER(S) (Including Area Code) 7 E MAIL ADDRESS (If applicable) 9 PLEASE PROVIDE THE NAME ADDRESS AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHEDA NAME a DEA benefit payment If you are planning to pursue a program of education for more than 45 months you should consider deferring ACCOUNT NUMBERROUTING OR TRANSIT NUMBERSAVINGS8 DIRECT DEPOSIT (Attach a voided personal check or provide the following information Direct Deposit is not available for DEA benefit payments) ACCOUNT TYPECHECKING ACTIVE DUTYC BRANCH OF SERVICE OR ADDITIONAL HELP COMPLETING APPLICATION aggravated in the line of duty in the active military naval or air service; and the serviceperson is likely to be an occupation A certification test is a test designed to provide affirmation of an individual's qualifications in a specific occupation APO/FPO AA APO/FPO AP Apply for Benefits " Ask him or her to submit your enrollment information using VA Form 22 1999 Enrollment Certification or its electronic version B ADDRESS B DEPENDENTS' INDEMNITY COMPENSATION (DIC) Be sure to do the following: benefits and in criminal penalties Buffalo NY 14240 4616 by hostile force forcibly detained or interned in line of duty by hostile force or forcibly detained or interned in line of C TELEPHONE NUMBER (Include Area Code) Central Region: CERTIFICATE certification showing the number of lessons completed For more information on correspondence courses please visit our website at CHAPTER 33 POST 9/11 GI BILL MARINE GUNNERY SERGEANT DAVID FRY SCHOLARSHIPA DISABILITY COMPENSATION OR PENSIONF NONE CHAPTER 35 SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE CHAPTER 35 SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE PROGRAM (DEA) claiming benefits has an outstanding felony warrant Any benefits paid to you for such period will result in an overpayment and be COLLEGE COLLEGE OR OTHER SCHOOLAPPRENTICESHIP OR OTHER ON THE JOB TRAININGFARM COOPERATIVENATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDITCORRESPONDENCE COURSE (DEA Children not eligible) complete this form VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed You are not COMPONENTD CHARACTER OF DISCHARGE COURSE OF STUDY FROMTOHIGH SCHOOL D VETERANS EDUCATION ASSISTANCE BASED ON YOUR OWN SERVICE SPECIFY BENEFIT(S): Decatur GA 30031 7022 decision If you decide to elect benefits under DEA indicate the date from which you wish your DEA payments to begin DEPARTMENT FOR THE SAME COURSES FOR WHICH YOU EXPECT TO Department of Veterans Affairs dependent in a compensation claim while receiving Survivors' and Dependents' Educational Assistance(DEA) CAREFULLY READ THE DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS DIPLOMA OR discharged or released from such service for such disability DISCONTINUED HIGH SCHOOL Do not use this form to apply for Veterans' education assistance based on your own service (chapters 30 32 33 1606 or 1607) or duty by foreign government or power for more than 90 days E VETERANS EDUCATION ASSISTANCE BASED ON SOMEONE ELSE'S SERVICE Eastern Region: EDUCATION BENEFITS PAMPHLET PLEASE CHECK THE BOX Educational Assistance program may be reimbursed for the cost of approved tests for admission to or credit at institutions of higher Eligibility for DEA will be terminated in the event that VA determines that the individual on whose account benefits are claimed is no EMPLOYEDD LICENSE OR RATING EMPLOYMENT EMPLOYMENT ) FEMALEMALE3 DATE OF BIRTH for receiving outpatient medical care services or treatment; has a total disability permanent in nature incurred or Foreign free at 1 888 GIBILL 1 (1 888 442 4551) If you use the Telecommunications Device for the Deaf (TDD) the Federal her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1 1975 and still in effect The requested HOURS COMPLETED HOW TO FILE YOUR CLAIM I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief If you need additional help completing this application or you want information about our work study program call VA toll IMPORTANT: Complete Items 28 and 29 only if you checked block "E" in Item 27 IMPORTANT:You may not receive payments of Dependency and Indemnity Compensation (DIC) or Pension and you may not be claimed as a IN INK INFORMATION AND INSTRUCTIONS (Continued) INFORMATION AND INSTRUCTIONS FOR COMPLETING THE information is considered relevant and necessary to determine the maximum benefits allowable under the law While you do not have to respond INSTRUCTIONS BEFORE COMPLETING THIS ELECTION BLOCK YOU ARE STRONGLY ENCOURAGED TO DISCUSS YOUR ELECTION WITH A INTERNET VERSION AVAILABLE You may complete and submit your application online at: www gibill va govPART I APPLICANT INFORMATION1 SOCIAL SECURITY NUMBER Islands ITEM 17 You will not be eligible to receive benefits for any period for which you or the qualifying individual on whose account you are ITEM 18 ITEM 26 Your election to receive Survivors' and Dependents' Educational Assistance (DEA) is final and cannot be changed This ITEMS 23 and 24 Any individual eligible under the Survivors' and Dependents' Educational Assistance program may receive Special JUL 2012 JUL 2012WHICH WILL NOT BE USED learning LICENSING OR CERTIFICATION TESTFLIGHT TRAINING (Fry Scholarship only) lip reading and Braille reading and writing Specialized Vocational Training consists of specialized courses leading to a suitable LOCATION OF SCHOOL longer totally disabled or VA is notified that the individual is no longer listed as captured missing in action or forcibly detained may receive benefits for correspondence training Payments for correspondence courses are made quarterly after VA receives a means that payments of compensation pension and Dependents' Indemnity Compensation (DIC) will be terminated upon issuance of medical certificate on the date that you enter training MISSING IN ACTION OR P O W Muskogee OK 74402 8888 NOTE: Complete Item 36 only if you are a civilian employee of the U S GovernmentYESNO NOTE: The number on the instructions match the item numbers on this application Items not mentioned are self explanatory OMB Approved No 2900 0098 OR TRADE OTHER other agencies P O Box 100022 P O Box 4616 P O Box 66830 P O Box 8888 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 page for the post office box address for these offices PART II QUALIFYING INDIVIDUAL INFORMATION10 NAME OF INDIVIDUAL ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (FIRST MIDDLE LAST) PART IV DEA APPLICANT AND ELECTION INFORMATION PART IX CERTIFICATION AND SIGNATURE OF APPLICANT PART V APPLICATION HISTORYG OTHER (Specify benefit(s) PART VI APPLICANT'S MILITARY SERVICE INFORMATION PART VII EDUCATION TRAINING AND EMPLOYMENTSECTION I EDUCATION & TRAINING PART VIII REMARKS REMINDERS AND VA EDUCATION BENEFITS PAMPHLETSECTION I REMARKS PENALTY: Willfully 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 Philippines planning your educational and/or career goals Services include educational and vocational guidance and testing to develop a greater PRIMARY PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized PROGRAM (DEA) pursuing an educational program Examples of Special Restorative Training include speech and voice correction language retraining QUARTER OR CLOCK receipt of DEA benefits We strongly recommend that you discuss your education or training plans with a VA counselor before making a RECEIVE VA EDUCATIONAL ASSISTANCE? (If "Yes " complete Item 36B) RECEIVED Refusal to provide your SSN by itself will not result in the denial of benefits VA will not deny an individual benefits for refusing to provide his or Relay number is 711 You can also get more information about education assistance from our education Internet site at 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 RESERVE OR GUARD Respondent Burden: 45 minutes RESPONDENT BURDEN: We need this information to determine your eligibility for education benefits (38 U S C 3513) Title 38 U S C allows Restorative Training or Specialized Vocational Training if a VA counselor determines that a specialized program is needed to overcome SCHOLARSHIP (FRY SCHOLARSHIP) SCHOOL34B NAME AND Schools SECONDARY SECTION I APPLICANT INFORMATION22 IF YOU ARE THE SPOUSE OF A DISABLED VETERAN IS A DIVORCE OR ANNULMENT PENDING? SECTION II ELECTION (CHILD APPLICANTS ONLY) SECTION II EMPLOYMENT35 CURRENT AND PAST EMPLOYMENTA EMPLOYERB JOB TITLEC NUMBER OF MONTHS SECTION II REMINDERSDID YOU REMEMBER TO: SECTION III VA EDUCATION BENEFITS PAMPHLET See reverse for the addresses of these VA Regional Processing Offices SEMESTER send comments or suggestions about this form SERVES THE FOLLOWING STATES SERVES THE FOLLOWING STATES service connected disability was rated permanent and total in nature SIGN HERE SOCIAL SECURITY NUMBER OF APPLICANT Southern Region: SPECIFY BENEFIT(S) BY CHECKING APPLICABLE BOX BELOW AND COMPLETE ITEMS 28 AND 29 SPOUSE SEEKING SPECIALIZED VOCATIONAL TRAINING? St Louis MO 63166 6830 Step 1: Mail the completed application to the VA Regional Processing Office for the region of that school's physical address Step 1: Mail the completed application to the VA Regional Processing Office for the region of your home address Check next Step 2: Tell the veterans certifying official at your school or training establishment that you have applied for VA education benefits Step 2: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits Step 3: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits subject to collection submit are considered confidential (38 U S C 5701) Information submitted is subject to verification through computer matching programs with SUPERSEDES VA FORM 22 5490 OCT 2011 SURVIVING SPOUSE SEEKING SPECIAL RESTORATIVE TRAINING? system of records 58VA21/22/28 Compensation Pension Education and Vocational Rehabilitation and Employment Records VA published in the effects of a physical or mental handicap To be eligible for receipt of specialized training the disability must prevent you from the Federal Register Your obligation to respond is required to obtain education benefits Giving us your SSN account information is voluntary To qualify for Survivors' and Dependents' Educational Assistance (DEA) you must be either TRANSFERRED ENTITLEMENTC VOCATIONAL REHABILITATION BENEFITS (Chapter 31) TYPE OF under the Privacy Act of 1974 or Title 38 Code of Federal Regulations 1 576 for routine uses (i e awards of benefits) as identified in the VA understanding of your skills talents and interests For more information on VA counseling call VA toll free at 1 888 GIBILL 1 us to ask for this information We estimate that you will need an average of 45 minutes to review the instructions find the information and US Virgin Use this form to apply for educational assistance under the following benefit programs: VA cannot process your claim for benefits unless the information is furnished as required by existing law (38 U S C 3513) The responses you VA COUNSELOR VA FORM VA FORM 22 5490 JUL 2012 VA FORM 22 5490 JUL 2012PAGE 2 VA FORM 22 5490 JUL 2012PAGE 3 VA FORM SUPERSEDES VA FORM 22 5490 OCT 2011 PAGE 1 VA Regional Office VA Regional Office VA VOCATIONAL AND EDUCATIONAL COUNSELING HELP AVAILABLE VA offers a wide range of services to assist you in valid first class medical certificate on the date that you enter training For all other flight courses you must have a valid second class VOCATIONAL vocational objective vocational rehabilitation benefits (chapter 31) To apply for veterans' education assistance based on your own service use VA Form Western Region: WHICH WILL NOT BE USED while serving on active duty as a member of the Armed Forces WRITE YOUR SOCIAL SECURITY NUMBER ON EACH PAGEWRITE YOUR COMPLETE MAILING ADDRESSATTACH SUPPORTING DOCUMENTS (e g birth certificate marriage license DD214 etc ) www gibill va gov YEARMONTHDAY YESNO YESNO YESNO(If "Yes " please provide date of remarriage) YESNOPART III BENEFIT AND TYPE OF EDUCATION OR TRAININGCHAPTER 33 POST 9/11 GI BILL MARINE GUNNERY SERGEANT JOHN DAVID FRY YESNOSPOUSESURVIVING SPOUSEADOPTED CHILDSTEPCHILDCHILD16 YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL17 DO YOU OR THE QUALIFYING INDIVIDUAL ON WHOSE ACCOUNT YOU ARE CLAIMING BENEFITS HAVE AN OUTSTANDING FELONY AND/OR WARRANT? YESNOYEARMONTHDAY