Form VA Form 22-0839 VA Form 22-0839 Yellow Ribbon Program Agreement

OMB Control No. 2900-0718
Respondent Burden: 10 minutes

YELLOW RIBBON PROGRAM AGREEMENT
(Under chapter 33 of title 38, United States Code)
IMPORTANT: Please read the instructions for VA Form 22-0839 on pages 3 & 4 before completing the form.
NAME OF INSTITUTION OF HIGHER LEARNING (IHL)

FACILITY CODE

MAILING ADDRESS OF INSTITUTION OF HIGHER LEARNING

Date Received (For VA use only)

(Check one)

Public IHL

Private IHL

The above named institution of higher learning (IHL) agrees to participate in the Yellow Ribbon Program under the
Post-9/11 GI Bill (authorized under title V of Public Law 110-252) subject to the terms, conditions, and representations
provided in this agreement and applicable VA regulations.
1. The IHL agrees to provide contributions to eligible individuals who apply for such program at the institution (in a
manner prescribed by the institution) on a first-come-first-served basis, regardless of the rate at which the individual is
pursuing training (i.e., full-time versus less than full-time), during the academic year.
2. The IHL agrees to provide contributions on behalf of a participating individual during the current academic year and all
subsequent academic years in which the IHL participates in the Yellow Ribbon Program, provided that the individual
maintains satisfactory progress, conduct, and attendance according to the regularly prescribed standards of the
institution.
3. The IHL agrees to limit contributions made on behalf of a participant to funds under the unrestricted control of the IHL
(e.g., a scholarship sent directly to an IHL on behalf of an individual or specific group of individuals from a third
party may not be included in Yellow Ribbon Program contributions). Funds received directly or indirectly from
Federal sources may not be counted towards contributions.
4. The IHL agrees to provide the maximum amount of contributions payable toward the unmet established charges to
each participating individual during each term, quarter, or semester the individual is enrolled if the IHL’s total
contribution toward the individual’s unmet established charges for the term, quarter, or semester do not exceed the
maximum dollar amount payable during the academic year as specified in paragraph 7 of this agreement.
5. The IHL agrees to provide contributions for each Yellow Ribbon Program participant using the following:
Direct Grant
Scholarship
Other_________________________
6. The IHL agrees to provide Yellow Ribbon Program contributions to up to__________ eligible individuals during
(total number)
the ______________ academic year.
(dates)

7. The IHL agrees to provide Yellow Ribbon Program contributions for each participant during the academic year up
to the following amounts (fill in all applicable fields):
A. MAXIMUM NUMBER
OF STUDENTS

B. DEGREE LEVEL
(Undergraduate, Graduate,
Doctoral, or All)

C. COLLEGE OR PROFESSIONAL
SCHOOL

D. MAXIMUM
CONTRIBUTION
AMOUNT
$
$
$
$
$
$
$
$
$
$
$
$

(Attach additional listings if necessary)
VA FORM
JAN 2010

22-0839

SUPERSEDES VA FORM 22-0839, NOV 2008,
WHICH WILL NOT BE USED.

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8. An IHL with multiple campuses that wishes to submit a single Yellow Ribbon Program agreement covering more
than one campus agrees to submit a listing of all campuses covered under this agreement as an addendum to this
agreement. The listing must include the name, address, and facility code of each campus. The IHL further certifies
that all campuses covered under this agreement are subject to the authority of the authorizing official signing the
agreement, and each campus has a certifying official or other employee who meets the requirements of section
21.4266(f)(3)(ii) of title 38, Code of Federal Regulations, and has access to the terms of this agreement.
9. This agreement is entered into under the authority of section 3317 of title 38, United States Code (as added by
section 5003 of Public Law 110-252, effective August 1, 2009) and section 21.9700 of title 38, Code of Federal
Regulations. The terms of this agreement will be effective for the entire academic year beginning on the first day
of August following the date of acceptance by a duly authorized officer of VA.
10. The terms of this agreement will be available for public viewing on VA’s GI Bill website at www.GIBILL.va.gov .
11. Completed agreements (with the original signature of an official legally authorized to bind the IHL to this
agreement) must be received by VA no later than May 21(or the following Monday if May 21 falls on a weekend)
of each calendar year for the following academic year. Late agreements may not be accepted.
12. The IHL certifies that at least 1 of its VA-approved programs has tuition and/or fees that exceed the maximum
rates payable by the Post-9/11 GI Bill at the time this document is being submitted.
13. Points of contact:
School Financial Representative/
Yellow Ribbon Program Point of Contact (POC)
Name (First, middle, last)

Telephone No. (Include Area Code)

E-mail

School Certifying Official
Name (First, middle, last)

Telephone No. (Include Area Code)

E-mail

RESPONDENT BURDEN: We need this information to determine your institution of higher learning’s eligibility to participate in the Yellow Ribbon Program.
Title 38 United States Code allows us to request this information. We estimate that you will need an average of 10 minutes to review the instructions, find
information, and complete the 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.VA.EPA.html#VA. You may also call 1-888-GIBILL-1 (1-888-442-4551) to get information on where to send
comments or suggestions about this information collection. Your obligation to respond is voluntary.

AGREED TO:
SIGNATURE OF AUTHORIZING OFFICIAL

TITLE OF AUTHORIZING OFFICIAL

TELEPHONE NUMBER

DATE SIGNED

FOR VA USE ONLY
ACCEPTED BY:
SIGNATURE OF VA OFFICIAL

DATE SIGNED

DATE ENTERED IN WEAMS

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INSTRUCTIONS FOR VA FORM 22-0839
YELLOW RIBBON PROGRAM AGREEMENT
Please read through the instructions before completing the Yellow Ribbon Program Agreement. If you have
any issues completing the form, please send an e-mail to Yellow.Ribbon@va.gov with any inquiries.
General Eligibility
The institution must be an Institution of Higher Learning (IHL) that offers programs of education approved
for VA benefits. In addition, the IHL must be located in the United States or be a branch of such institution
located outside of the United States. Foreign schools are not eligible to participate in the Yellow Ribbon
Program.
Name, Address, & Facility Code
Enter the name, mailing address, and facility code of the IHL.
Items 1-4
By signing and submitting this form to VA, the IHL agrees to adhere to the provisions listed in
Items 1-4
Item 5
Check only one box. If other is specified, provide the form of contribution in the space required. Refer to
Line 3 concerning prohibited sources of funds for institutional contributions.
Item 6
Enter the total number of students for which the IHL will provide Yellow Ribbon Program contributions.
The total number of students entered here should equal the sum of students listed in column A of the table
in Item 7. Enter the dates of the upcoming academic year (e.g., 2010-2011, 2011-2012) for which the
agreement is being submitted.
Item 7
A. Maximum Number of Students - Enter the maximum number of students eligible for the specific
contribution. If the IHL wishes to offer Yellow Ribbon Program contributions to an unlimited number of
qualifying students, enter 99999.
B. Degree Level - Specify the degree level (undergraduate, graduate, doctoral, all) of students for which the
specific contribution will be provided.
C. College or Professional School - Specify the appropriate subelement (college or professional school) of
the institution for which students must be enrolled to receive the specific contribution. Please be advised
that an IHL cannot list a specific degree program (e.g., Masters of Business Administration, Juris
Doctorate, Bachelor of Science in Nursing, etc.)
D. Maximum Contribution Amount - Specify the maximum annual contribution amount to be provided for
each student eligible for the specific contribution. Do not enter the maximum amount payable by term or
credit hour. If the IHL wishes to provide 50% of the unmet established charges for each student eligible for
the specific contribution, please enter 99999.
NOTE: IHL’s must complete columns A and D for each contribution listed. IHL’s must also complete column
C, column D, or both columns C and D for each contribution listed.
EXAMPLE:
A. MAXIMUM NUMBER
OF STUDENTS

10

B. DEGREE LEVEL
(Undergraduate, Graduate,
Doctoral, or All)

$ 2,000

Undergraduate

15
20

C. COLLEGE OR PROFESSIONAL D. MAXIMUM CONTRIBUTION
SCHOOL
AMOUNT

Graduate

School of Liberal Arts

$ 1,000

School of Business

$ 5,000

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INSTRUCTIONS FOR VA FORM 22-0839
YELLOW RIBBON PROGRAM AGREEMENT (Continued)
Item 8
IHL’s may enter into a centralized Yellow Ribbon Program agreement. If an IHL has multiple campuses (that
are all subject to the authority of the official signing the agreement) and want to use the same contribution
information for multiple campuses, it may do so by attaching an addendum to this agreement which lists
name, mailing address, and facility code of each participating campus.
NOTE: Each campus will be held to the terms specified in the agreement.
Items 9 and 10
Self-explanatory
Item 11
Yellow Ribbon Program Agreements must be received by VA no later than May 21st (or the following
Monday if May 21st falls on a Saturday or Sunday) to be considered for participation.
Item 12
By signing and submitting this agreement, an IHL certifies that, as of the date the agreement is signed, at
least one of its VA approved programs are assessed tuition and/or fees that exceed the maximum amounts
payable in the state or territory under the Post-9/11 GI Bill.
Item 13
Enter the contact information for the school financial representative/Yellow Ribbon Program Point of Contact
(POC) and the School Certifying Official. These contacts may or may not be the same individual.

SIGNATURE OF AUTHORIZING OFFICIAL
The signature must be from an official legally authorized to bind the institution to this agreement with the
VA. The title, telephone number, and date must be provided.

The form may be submitted in the following manner:
1. Via e-mail to Yellow.Ribbon@va.gov . If submitting via e-mail, please attach a scanned copy of the
signed form. (VA cannot process applications received without a signature.)
2. Via fax to 202-275-2636 with a cover sheet displaying Attn: Yellow Ribbon Team.
3. Via postal mail to the following address:
Department of Veterans Affairs
Attn: Yellow Ribbon Program (225D)
810 Vermont Avenue, NW
Washington, DC 20420

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