Form 22-1990t Application for Individualized Tutorial Assistance

OMB Approved No. 2900-0171
Respondent Burden: 30 minutes

APPLICATION FOR INDIVIDUALIZED TUTORIAL ASSISTANCE
1. NAME OF
APPLICANT A. FIRST NAME
2. NAME OF
VETERAN (If
other than
A. FIRST NAME
applicant)
3. MAILING ADDRESS

B. M.I.

C. LAST NAME

B. M.I.

C. LAST NAME
4A.VA FILE NO./PAYEE NO. (Complete Item 4A and/or 4B)

A. NUMBER AND STREET OR RURAL ROUTE

4B. SOCIAL SECURITY NUMBER

B. APARTMENT OR BOX NUMBER
5. SEX

C. CITY OR POST OFFICE

6. DATE OF BIRTH

FEMALE
D. STATE

MALE

E. ZIP CODE OR FOREIGN MAIL CODE

7. NAME OF YOUR COURSE OR CURRICULUM

8. CREDIT OR CLOCK HOUR LOAD

10. UNIT SUBJECT OR SUBJECTS IN WHICH YOU REQUIRE INDIVIDUALIZED
TUTORING

MONTH

YEAR

DAY

9. FINAL EDUCATIONAL, PROFESSIONAL, OR
VOCATIONAL GOAL

11. NAME, POSITION, AND ADDRESS OF TUTOR

12. SCHEDULE AND CHARGES FOR TUTORIAL ASSISTANCE
A. MONTH AND
YEAR

B. EXACT DATES
OF SESSIONS

C. NUMBER OF HOURS
OF INSTRUCTION
THIS MONTH

D. CHARGE PER
HOUR

E. TOTAL CHARGES
THIS MONTH

F. TOTAL PAYMENT DUE
13A. SIGNATURE OF APPLICANT (Do NOT print)

13B. DATE SIGNED

13C. E-MAIL ADDRESS OF APPLICANT

I CERTIFY THAT: (1) I gave the applicant individualized tutorial assistance as shown above; (2) the charges to the applicant shown
above are correct; and (3) I am not a close relative (i.e., spouse, parent, child, brother, sister) of the applicant.
14A. SIGNATURE OF TUTOR (Do NOT print)

14B. DATE SIGNED

I CERTIFY THAT: (1) The individualized tutorial assistance for the unit subject or subjects shown was required for the satisfactory
pursuit of the student’s approved program; (2) the tutor is qualified to conduct individualized tutorial assistance; and (3) the charges
do not exceed the customary charges for other students who receive the same tutorial assistance.
15. NAME AND ADDRESS OF EDUCATIONAL INSTITUTION

16. INDICATE TYPE OF SCHOOL
FOUR -YEAR
COLLEGE

17A. SIGNATURE AND TITLE OF CERTIFYING OFFICIAL

TWO-YEAR
COLLEGE

OTHER THAN
COLLEGE

17B. DATE SIGNED

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.
FOR VA USE ONLY
APPROVAL DATE

VA FORM
NOV 2008

SIGNATURE OF ADJUDICATOR

22-1990t

SIGNATURE OF FINANCE OFFICER (or designee)

EXISTING STOCKS OF VA FORM 22-1990t, MAY 2008,
WILL BE USED.

DATE

STATION
NUMBER

INFORMATION AND INSTRUCTIONS
GENERAL INFORMATION: To apply for tutorial
assistance read these instructions and complete the form in
full. If you need help, reach us the Internet at
http://www.gibill.va.gov. You can call VA toll-free at
1-888-GIBILL-1 (1-888-452-4551) . If you are hearing
impaired, call VA toll-free on 1-800-829-4833. You can also
reach us on the World Wide Web. The address is:
www.GIBILL.va.gov. To obtain information on other forms of
assistance, contact the financial aid office at your school.
ELIGIBILITY: If you are eligible for education benefits and
you need help in a subject, you can get supplemental payments
for tutorial assistance. The subject must be necessary for the
completion of your approved program. You must be training at
one-half time or more in a post-secondary program at an
educational institution. Even if you are passing a course, you
can get tutorial assistance if your grade will not be credited
toward completion of your program.

CLAIMS FOR TUTORIAL ASSISTANCE: After you

EASTERN REGION
VA Regional Office
PO Box 4616
Buffalo, NY 14240-4616

CT
MA
DE
NH
DC
NJ
ME
NYO
MD
H
Foreign Schools

PA
RI
VT
VA
WV

CENTRAL REGION
VA Regional Office
PO Box 66830
St. Louis, MO 63166-6830

CO
IA
IL
IN
KS

NE
ND
SD
TN
WI
WY

WESTERN REGION
VA Regional Office
PO Box 8888
Muskogee, OK 74402-8888

ID
AK
LA
AR
NM
AZ
NV
CA
OK
HI
Philippines

OR
TX
UT
WA

SOUTHERN REGION
VA Regional Office
PO Box 100022
Decatur, GA 30318-7022

AL
FL
GA

SC

have received tutoring, do the following:
Step 1. Fill out the form.

.
.
.

Complete Items 1 through 13.
In Item 10, show the individual unit subject or subjects
(e.g., Math 101) for which you needed tutoring.
Be sure to complete all blocks A through E in Item 12.
If any block is not checked, your payment may be
delayed.

Step 2. Take to your tutor. The tutor must:

..
.

Sign and date the application in Items 14A and 14B.
Verify the information you provided.
Certify that he or she is the person who gave you
individualized tutoring, and is not closely related to you
(i.e., spouse, parent, brother, sister or child).

Step 3. Take to the certifying official for VA Benefits at the
school. The certifying official must:

.
.

Complete Items 15 and 16.
Sign in Items 17A and 17B.

Step 4. Review of Form. After you have a completed form
(see steps 1 through 3), send it to VA as soon as possible after
you tutoring is complete. VA will not pay assistance for any
tutoring received more than one year before the day VA actually
receives your claim.

KY
MI
MN
MO
MT

MS
NC
PR

US Virgin Islands

Step 5. Where to Mail This Form. Mail the completed form
to the Regional Processing Office for the state where your
school is located. See the chart above.

PAYMENTS: VA will pay up to $100 per month for your
tutorial assistance. The tutorial assistance you get will be in
addition to your regular monthly education benefits for going to
school.

ENTITLEMENT: The limit for tutorial assistance is $1,200
(12 times the maximum monthly rate of $100).
Special provisions:
1. If you are training under 38 U.S.C. Chapter 30 or 32, or
under 10 U.S.C. Chapter 1606, or Section 903 of Public Law
96-342, VA will not charge entitlement for your first $600 of
tutorial assistance. For tutorial assistance over $600, VA will
charge one month of entitlement whenever you receive an
amount equal to the full-time monthly rate you get for going to
school.
2. If you are training under 38 U.S.C. Chapter 33 or 35, or the
Omnibus Diplomatic Security and Antiterrorism Act of 1986,
VA will not charge you any entitlement for tutorial assistance.

PRIVACY ACT NOTICE: 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 Tile 38, Code of Federal Regulations 1.576 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 claim forms or (2) for VA to obtain further information as may be necessary from the
school for 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 Vocational Rehabilitation Records - VA , and published in the Federal Register. Your obligation to respond is
required to obtain or retain education benefits. While you do not have to respond, VA cannot process your claim for tutorial assistance unless the information is
furnished as required by existing law (38 U.S.C. 3019, 3234, 3314, 3492, and 3533 and 10 U.S.C. 16131). 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 eligibility for tutorial assistance. We cannot determine your eligibility to tutorial assistance
until we receive this information (38 U.S.C. 1692). Title 38, United States Code, allows us to ask for this information. We estimated that you will need an average of
30 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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. 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 22-1990t, NOV 2008