Form VA Form 22-5490 VA Form 22-5490 Dependents' Application For VA Education Benefits

DRAFT

OMB Approved No. 2900-0098
Respondent Burden: 30 minutes

DEPENDENTS’ APPLICATION FOR VA EDUCATION BENEFITS
(Under Provisions of chapters 33 and 35, of title 38,U.S.C.)
INTERNET VERSION AVAILABLE - You may complete and submit your application online at: www.gibill.va.gov

PART I - APPLICANT INFORMATION
1. SOCIAL SECURITY NUMBER

2. SEX OF APPLICANT

MALE

3. DATE OF BIRTH

FEMALE

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)
SECONDARY

PRIMARY

(

)

(

)

7. E-MAIL ADDRESS (If applicable)

8. DIRECT DEPOSIT (Attach a voided personal check or provide the following information. Direct Deposit is not available for DEA benefit payments)
ROUTING OR TRANSIT NUMBER

ACCOUNT TYPE
CHECKING

ACCOUNT NUMBER

SAVINGS

9. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
A. NAME

B. ADDRESS

C. TELEPHONE NUMBER (Include Area Code)

PART II - QUALIFYING INDIVIDUAL INFORMATION
10. NAME OF INDIVIDUAL ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (FIRST- MIDDLE -LAST)

11. SOCIAL SECURITY NUMBER OR VA FILE NUMBER

13. DATE OF BIRTH (Mo., day, year)

12. BRANCH OF SERVICE

14. DATE OF DEATH OR DATE LISTED AS
MISSING IN ACTION OR P.O.W. (Mo., day, yr.)

15. IS QUALIFYING INDIVIDUAL CURRENTLY ON ACTIVE DUTY?

NO

YES
16. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL
SPOUSE

SURVIVING SPOUSE

CHILD

STEPCHILD

ADOPTED CHILD

17. DO YOU OR THE QUALIFYING INDIVIDUAL ON WHOSE ACCOUNT YOU ARE CLAIMING BENEFITS HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
YES

NO

PART III - BENEFIT AND TYPE OF EDUCATION OR TRAINING
18A. CHAPTER 35 - SURVIVORS’ AND DEPENDENTS’ EDUCATIONAL ASSISTANCE
PROGRAM (DEA)

18B. CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY
SERGEANT JOHN DAVID FRY SCHOLARSHIP
(FRY SCHOLARSHIP)

COLLEGE OR OTHER SCHOOL
INSTITUTION OF HIGHER LEARNING
FARM COOPERATIVE
LICENSING OR CERTIFICATION TEST
LICENSING OR CERTIFICATION TEST

VA DATE STAMP
APPRENTICESHIP OR OTHER ON-THE-JOB TRAINING

(For VA Use Only)

NATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDIT

CORRESPONDENCE COURSE (Spouse or Surviving Spouse only)

VA FORM
DEC 2009

22-5490

EXISTING STOCKS OF VA FORM 22-5490, JAN 2009,
WILL BE USED.

PAGE 1

SOCIAL SECURITY NUMBER OF APPLICANT
19. NAME AND ADDRESS OF SCHOOL OR TRAINING FACILITY (Number and street or rural route, city or P.O., State and ZIP Code)

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
MONTH

YEAR

DAY

PART IV - DEA APPLICANT AND ELECTION INFORMATION
(Fry Scholarship Applicants, Skip to Part V)
SECTION I - APPLICANT INFORMATION
22. IF YOU ARE THE SPOUSE OF A DISABLED VETERAN, IS A DIVORCE OR ANNULMENT PENDING?
YES
NO
23. ARE YOU A HANDICAPPED CHILD (14 YEARS OR OLDER), SPOUSE, OR
SURVIVING SPOUSE SEEKING SPECIAL RESTORATIVE TRAINING?

24. ARE YOU A HANDICAPPED CHILD, SPOUSE, OR SURVIVING
SPOUSE SEEKING SPECIALIZED VOCATIONAL TRAINING?

YES
YES
NO
NO
25. IF YOU ARE THE SURVIVING SPOUSE OF A DECEASED VETERAN, HAVE YOU REMARRIED SINCE HIS OR HER DEATH?
MONTH
YES

DAY

YEAR

(If "Yes," please provide date of remarriage)

NO

SECTION II - ELECTION (CHILD APPLICANTS ONLY)

IMPORTANT: You may not receive payments of Dependency and Indemnity Compensation (DIC) or Pension and you may not be
claimed as a dependent in a compensation claim while receiving Survivors’ and Dependents’ Educational Assistance (DEA).
CAREFULLY READ THE INSTRUCTIONS BEFORE COMPLETING THIS ELECTION BLOCK. YOU ARE STRONGLY ENCOURAGED
TO DISCUSS YOUR ELECTION WITH A VA COUNSELOR.
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:
MONTH

DAY

YEAR

PART V - APPLICATION HISTORY
27. PRIOR TO THIS APPLICATION, HAVE YOU EVER APPLIED FOR OR RECEIVED ANY OF THE FOLLOWING VA BENEFITS? (Check all appropriate boxes)
A.

DISABILITY COMPENSATION OR PENSION

B.

DEPENDENTS’ INDEMNITY COMPENSATION (DIC)

C.

VOCATIONAL REHABILITATION BENEFITS (Chapter 31)

D.

VETERANS EDUCATION ASSISTANCE BASED ON YOUR OWN SERVICE SPECIFY BENEFIT(S): ______________________________________

E.

VETERANS EDUCATION ASSISTANCE BASED ON SOMEONE ELSE’S SERVICE SPECIFY BENEFIT(S) BY CHECKING APPLICABLE BOX BELOW
AND COMPLETE ITEMS 28 AND 29
CHAPTER 35 - SURVIVORS’ AND DEPENDENTS’ EDUCATIONAL ASSISTANCE PROGRAM (DEA)
CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY SERGEANT DAVID FRY SCHOLARSHIP
TRANSFERRED ENTITLEMENT

F.

NONE

G.

OTHER (Specify benefit(s)__________________________________________________________________________

IMPORTANT: Complete Items 28 and 29 only if you checked block "E" in Item 27
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

PART VI - APPLICANT’S MILITARY SERVICE INFORMATION
(Note: Chapter 35 benefits are not payable while an eligible person is on active duty)
30. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES? (If "No," skip to Part VII)
YES

NO

31. INFORMATION ABOUT YOUR PERIOD(S) OF ACTIVE DUTY
A. DATE ENTERED ACTIVE DUTY

B. DATE SEPARATED FROM
ACTIVE DUTY

C. BRANCH OF SERVICE OR
RESERVE OR GUARD

D. CHARACTER OF DISCHARGE

PAGE 2

SOCIAL SECURITY NUMBER OF APPLICANT

PART VII - EDUCATION, TRAINING, AND EMPLOYMENT
SECTION I - EDUCATION & TRAINING
32. CHECK THE APPROPRIATE BOX AND ENTER THE DATE IN ITEM 33

33. DATE

GRADUATED FROM HIGH SCHOOL

DISCONTINUED HIGH SCHOOL

EXPECT TO GRADUATE FROM HIGH

AWARDED GED

NEVER ATTENDED HIGH SCHOOL

34A.
TYPE OF
SCHOOL

34B. NAME AND
LOCATION OF SCHOOL
(City and State)

34C. DATES OF TRAINING
FROM

TO

34D. NUMBER OF
SEMESTER, QUARTER,
OR CLOCK HOURS
COMPLETED

34E. DEGREE,
DIPLOMA, OR
CERTIFICATE
RECEIVED

34F. MAJOR FIELD OR
COURSE OF STUDY

HIGH SCHOOL

COLLEGE
VOCATIONAL
OR TRADE
OTHER
(Specify)
__________
__________
__________

SECTION II - EMPLOYMENT
35. CURRENT AND PAST EMPLOYMENT
A. EMPLOYER

B. JOB TITLE

C. NUMBER OF MONTHS
EMPLOYED

D. LICENSE OR RATING

NOTE: Complete Item 36 only if you are a civilian employee of the U.S. Government
36A. DO YOU EXPECT TO RECEIVE FUNDS FROM YOUR AGENCY OR DEPARTMENT
FOR THE SAME COURSES FOR WHICH YOU EXPECT TO RECEIVE VA
EDUCATIONAL ASSISTANCE? (If "Yes," complete Item 36B)
YES

36B. SOURCE OF EDUCATIONAL ASSISTANCE FROM GOVERNMENT
EMPLOYMENT

NO

PART VIII - REMARKS, REMINDERS AND VA EDUCATION BENEFITS PAMPHLET
SECTION I - REMARKS
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)

SECTION II - REMINDERS
DID YOU REMEMBER TO:
WRITE YOUR SOCIAL SECURITY NUMBER ON EACH PAGE

.
. YOUR COMPLETE MAILING ADDRESS
WRITE
.
ATTACH
SUPPORTING DOCUMENTS (e.g., birth certificate, marriage license, DD214, etc.)
SECTION III - VA EDUCATION BENEFITS PAMPHLET

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
EDUCATION BENEFITS PAMPHLET PLEASE CHECK THE BOX.

PART IX - CERTIFICATION AND SIGNATURE OF APPLICANT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.
39A. SIGNATURE OF (Check one) (DO NOT PRINT)

39B. DATE SIGNED

SIGN HERE
IN INK

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 benefits and in criminal penalties.
PAGE 3

(Please detach at perforation and retain this information for future reference)
INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
DEPENDENT’S APPLICATION FOR VA EDUCATION BENEFITS
(VA FORM 22-5490)
Use this form to apply for educational assistance under the following benefit programs:

. Survivors’ and Dependents’ Educational Assistance Program (DEA) (chapter 35 of title 38, U.S. Code)
. Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship (Fry Scholarship)
(chapter 33 of title 38, U.S. Code)
Do not use this form to apply for Veterans’ education assistance based on your own service (chapters 30, 32, 33, 1606, or 1607) or
vocational rehabilitation benefits (chapter 31). To apply for veterans’ education assistance based on your own service, use VA Form
22-1990. To apply for vocational rehabilitation benefits, use VA Form 28-1900.
INTERNET VERSION AVAILABLE - You may complete and submit this application on-line at www.gibill.va.gov. Click on "GI Bill:
Apply for Benefits."
VA VOCATIONAL AND EDUCATIONAL COUNSELING HELP AVAILABLE - VA offers a wide range of services to assist you in
planning your educational and/or career goals. Services include educational and vocational guidance and testing to develop a
greater understanding of your skills, talents, and interests. For more information on VA counseling, call VA toll-free at
1-888-GIBILL-1 (1-888-442-4551) or TDD at 1-800-829-4833.
NOTE: The number on the instructions match the item numbers on this application. Items not mentioned are self-explanatory.
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
claiming benefits has an outstanding felony warrant. Any benefits paid to you for such period will result in an overpayment and be
subject to collection.
ITEM 18.
18A. Select the benefit for which you are applying.
To qualify for Survivors’ and Dependents’ Educational Assistance (DEA) you must be either (1) The spouse or child of a veteran who is permanently and totally disabled as a result of a service-connected disability.
(2) The spouse or child of an individual on active duty who has been listed as missing in action, captured in line of duty
by hostile force, forcibly detained or interned in line of duty by hostile force, or forcibly detained or interned in line of
duty by foreign government or power for more than 90 days.
(3) The surviving spouse or child of a veteran who died of a service-connected disability or who dies while a
service- connected disability was rated permanent and total in nature.
(4) The spouse or child of an individual on active duty for which the evidence shows that the individual is hospitalized
for receiving outpatient medical care services or treatment; has a total disability permanent in nature incurred or
aggravated in the line of duty in the active military, naval, or air service; and the serviceperson is likely to be
discharged or released from such service for such disability.
Eligibility for DEA will be terminated in the event that VA determines that the individual on whose account benefits are claimed is no
longer totally disabled or VA is notified that the individual is no longer listed as captured, missing in action, or forcibly detained.
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
while serving on active duty as a member of the Armed Forces.
18A. & 18B. Types of education or training programs are self-explanatory, except for the following "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
an occupation. A certification test is a test designed to provide affirmation of an individual’s qualifications in a specific occupation.
"National Admission Exam or National Exam for Credit." Individuals eligible to receive benefits under the Survivors’ and Dependents’
Educational Assistance program may be reimbursed for the cost of approved tests for admission to or credit at institutions of higher
learning.
"Correspondence." Only spouses and surviving spouses eligible for the Survivors’ and Dependents’ Educational Assistance program
may receive benefits for correspondence training. Payments for correspondence courses are made quarterly after VA receives a
certification showing the number of lessons completed. For more information on correspondence courses, please visit our website at
www.gibill.va.gov.

VA FORM
DEC 2009

22-5490

EXISTING STOCKS OF VA FORM 22-5490, JAN 2009,
WILL BE USED.

INFORMATION AND INSTRUCTIONS (Continued)
ITEMS 23 and 24. Any individual eligible under the Survivors’ and Dependents’ Educational Assistance program may receive Special
Restorative Training or Specialized Vocational Training if a VA counselor determines that a specialized program is needed to
overcome the effects of a physical or mental handicap. To be eligible for receipt of specialized training, the disability must prevent you
from pursuing an educational program. Examples of Special Restorative Training include speech and voice correction, language
retraining, lip reading, and Braille reading and writing. Specialized Vocational Training consists of specialized courses leading to a
suitable vocational objective.
ITEM 26. Your election to receive Survivors’ and Dependents’ Educational Assistance (DEA) is final and cannot be changed. This
means that payments of compensation, pension, and Dependents’ Indemnity Compensation (DIC) will be terminated upon issuance of
a DEA benefit payment. If you are planning to pursue a program of education for more than 45 months, you should consider deferring
receipt of DEA benefits. We strongly recommend that you discuss your education or training plans with a VA counselor before making
a decision. If you decide to elect benefits under DEA, indicate the date from which you wish your DEA payments to begin.

HOW TO FILE YOUR CLAIM
Be sure to do the following:

(A) If you have selected a school or training establishment:
Step 1: Mail the completed application to the VA Regional Processing Office for the region of that school’s physical address.
See reverse for the addresses of these VA Regional Processing Offices.
Step 2: Tell the veterans certifying official at your school or training establishment that you have applied for VA education
benefits. Ask him or her to submit your enrollment information using VA Form 22-1999, Enrollment Certification, or its electronic
version.
Step 3: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.

(B) If you have not selected a school or training establishment:
Step 1: Mail the completed application to the VA Regional Processing Office for the region of your home address.
Check reverse for the post office box address for these offices.
Step 2: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.

ADDITIONAL HELP COMPLETING APPLICATION
If you need additional help completing this application or you want information about our work-study program, call VA
toll-free at 1-888-GIBILL-1 (1-888-442-4551). If you are hearing impaired, call us toll-free at 1-800-829-4833. You can
also get more information about education assistance from our education Internet site at www.gibill.va.gov.

Eastern Region:
VA Regional Office
P. O. Box 4616
Buffalo, NY 14240-4616

Central Region:
VA Regional Office
P. O. Box 66830
St. Louis, MO 63166-6830

SERVES THE FOLLOWING STATES

SERVES THE FOLLOWING STATES

CT

DE

DC

ME

CO

IA

IL

IN

MD

MA

NH

NJ

KS

KY

MI

MN

NY

OH

PA

RI

MO

MT

NE

ND

VT

VA

WV

Foreign
Schools

SD

TN

WY

WI

Western Region:
VA Regional Office
P. O. Box 8888
Muskogee, OK 74402-8888

Southern Region:
VA Regional Office
P. O. Box 100022
Decatur, GA 30031-7022

SERVES THE FOLLOWING STATES

SERVES THE FOLLOWING STATES

AK

AR

AZ

CA

AL

FL

GA

MS

HI

ID

LA

NM

NC

PR

SC

US Virgin
Islands

NV

OK

OR

Philippines

TX

UT

WA

GUAM

APO/FPO AA

APO/FPO AP

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., awards of benefits) as identified in the VA system of
records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation Records and Employment Records - VA, published in
the Federal Register. Your obligation to respond is required to obtain education benefits. Giving us your SSN account information is voluntary.
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
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
information is considered relevant and necessary to determine the maximum benefits allowable under the law. While you do not have to respond,
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
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 your eligibility for education benefits (38 U.S.C. 3513). Title 38 U.S.C. allows
us to ask for this information. We estimate 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
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.