Form FL21-863 Request for Information to Make Direct Payment to Child

DEPARTMENT OF VETERANS AFFAIRS

.

In Reply Refer To:

You have been receiving VA benefits for
attendance beyond age 18.

based on school

Our records show that this student will reach age of majority in
and, thereafter, will be entitled to receive direct payment.
VA payments may be continued up to the student’s 23rd birthday, but will be terminated before then if
the student marries, completes the course of study, or withdraws from school.
To avoid any delay in future checks, the student must furnish the information requested below. Answer
Items 1A through 7, and return this letter to this office as soon as possible. If you have any questions,
call 1-800-827-1000 (Hearing Impaired TDD line 1-800-829-4833).
Sincerely yours,
OMB Control No. 2900-0215
Respondent Burden: 10 Mins.
PRIVACY ACT INFORMATION: 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 1.576 for routine uses (i.e., civil or criminal law
enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States,
litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification
of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22, Compensation, Pension,
Education and Rehabilitation Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain
benefits. Information that you furnish may be utilized in computer matching programs with other Federal or State agencies for the purpose of
determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation
in any benefits program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: We need this information to determine continued eligibility for death benefits and entitlement to direct payment
(38 U.S.C. 1313 and 1542). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of
10 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
www.whitehouse.gov/library/omb/OMBINV.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send
comments or suggestions about this form.
1A. STUDENT’S ADDRESS (For check mailing purposes)
TELEPHONE NUMBER(S) (Include Area Code)
1B. DAYTIME
1C. NIGHTTIME
2A. IS STUDENT ATTENDING SCHOOL?

2B. NAME AND ADDRESS OF SCHOOL

YES (If "Yes," complete Items 2B and 2C)
NO (If "No," complete Items 3 and 4)
2C. DATE OF GRADUATION
(Anticipated date of graduation or
completion of course of study)
3. DATE SCHOOL ATTENDANCE TERMINATED (Mo., day, yr.)
5A. IS STUDENT MARRIED?
YES
NO
6. SIGNATURE

4. REASON FOR TERMINATION OF ATTENDANCE

5B. DATE OF MARRIAGE (Mo., day, year)

5C. PLACE OF MARRIAGE (City, State or Country)
7. DATE
FL 21-863
Oct 2004(R)