Form VA Form 21-8960 VA Form 21-8960 Certification of School Attendance or Termination

File Number:

Name of Student:
Birth Date of Student:

Because we are paying Department of Veterans Affairs benefits based on your report that the student named
above is attending school, we ask that you verify the student’s school attendance for this school year. Please
answer the questions below, sign and date the form, and return it within 60 days to the VA office address
shown above. Otherwise, benefits based upon the student’s school attendance will be discontinued.
DEPARTMENT OF VETERANS AFFAIRS
OMB Approved No. 2900-0458
Respondent Burden: 10 minutes

CERTIFICATION OF SCHOOL ATTENDANCE OR TERMINATION
1. IS THE STUDENT NOW IN SCHOOL?
(If "No," do NOT complete Items 2 and 4. Give the date and reason school attendance terminated)
YES

NO

2. HAS THE STUDENT ATTENDED SCHOOL FROM THE OFFICIAL BEGINNING DATE OF THE SCHOOL YEAR? 3. IS THE STUDENT MARRIED?
(If "No,"enter the inclusive dates of the student’s school attendance)
YES

YES

NO

4. NAME OF LAST SCHOOL ATTENDED

5. HAS THE STUDENT ATTENDED ANY OTHER
SCHOOL(S) THIS YEAR?
YES

NO

(If "Yes,"enter the name(s) and
address(es) below)

(If "Yes," give the date
NO married below)

6. WHEN DOES THE STUDENT EXPECT TO
GRADUATE OR OTHERWISE
TERMINATE THE COURSE OF STUDY?
(Give date)

NOTE: The student should sign this form only if the student is receiving benefits in his or her own right. Otherwise,
the parent, guardian, or custodian should sign in Item 7 and enter his or her relationship to the student in Item 8.
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 attendance, or marriage
prior to completion of the course. I understand that continued entitlement to school attendance benefits may be based on information I have furnished on this form. Any benefits
allowed due to this certification will be discontinued if the student marries or leaves school, or upon the death of the student.

I CERTIFY THAT the information provided is true and correct to the best of my knowledge and belief.
7. SIGNATURE

10. DAYTIME PHONE NUMBER (Include Area Code)

8. RELATIONSHIP TO STUDENT

9. DATE SIGNED

11. EVENING PHONE NUMBER (Include Area Code)

PRIVACY ACT INFORMATION: 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 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, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested information
is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information
submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine continued eligibility to benefits for a veteran’s child who is over age 18 and attending school (38 U.S.C.
101). 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/omb/library/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.

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 is false, or fraudulent acceptance of any payment to which you are not entitled.
VA FORM
FEB 2005

21-8960