VA Form 22-8692 Student Work-Study Agreement (Advance Payment)

OMB Approved No. 2900-0209
Respondent Burden: 5 minutes

STUDENT WORK-STUDY AGREEMENT (ADVANCE PAYMENT)
VA FILE NUMBER:

AGREEMENT NUMBER:

PRIVACY ACT INFORMATION: VA will not disclose information collected by this information collection to any source other than what has been authorized by the Privacy Act of 1974 or Title 38 Code of
Federal Regulations 1.576 for routine uses as identified in VA’s system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation Records - VA as published in the Federal
Register at http://www.rms.oit.va.gov/SOR_Records/58VA21_22.asp. An example of a routine use allows VA to send 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 claims 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. Your obligation to respond is "required to obtain or retain benefits." We cannot pay you any VA work-study benefits until we
receive this information (38 U.S.C. 3485). Your responses are 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 acceptance of the VA work-study terms shown on this information collection. Title 38 United States Code allows us to ask for this
information. We estimate that you will need an average of 5 minutes to review the instructions, find the information and complete the form. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is 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 information collection.

NOTE: VA will complete the hourly rate item below with the federal minimum wage or your State minimum wage rate, whichever is greater. If you have any questions
concerning this hourly rate, contact your nearest VA office at 1-800-827-1000.

I,
(student), agree to perform
hours of service for the Department of Veterans Affairs (VA) during the period
starting on or about
and ending no later than
(agreement period), in consideration of which VA agrees to pay me a total work-study allowance of $
, subject to
the following terms, conditions and representations:
1. VA will designate and assign the services to be performed by me at various times during the agreement period and my performance will
be subject to VA supervision.
2. While performing such services, I (a) will not be considered an employee of the United States for the purpose of laws administered by the
Office of Personnel Management, but I will be considered such an employee for the purpose of receiving benefits under the provisions of
chapter 81 of title 5, U.S.C. (Compensation for Work Injuries); (b) will not receive or accept compensation from any other source for the
same hours of work performed under this agreement with the following exceptions: (1) If I am attending a college or university, I can
receive from that institution the difference between what the VA pays and the amount that the institution would otherwise pay to work-study
students performing similar services and (2) payment from an AmeriCorps Education Award; and (c) will not disclose to anyone any
information contained in VA files, records, reports, and other documents made available to me while performing such services except as
provided by the Privacy Act of 1974 (5 U.S.C. 552a), pertinent provisions of title 38, U.S.C., and supplementary regulations.
3. In return for my services under this agreement, VA will pay me a work-study allowance at the rate of $
for each hour of service I
satisfactorily perform under this agreement. (In no event may I perform more hours of service than the product of 25 times the number of
weeks in my actual period(s) of enrollment during the agreement period.)
4. Upon VA acceptance of this agreement, VA will advance me the lesser or either forty percent (40%) of the total amount of the work-study
allowance under this agreement or the amount payable for the first 50 hours of service to be performed. Not more than one advance payment
may be made in any school term (or four month period if my course is not organized on a term basis). Payment for any remaining hours of
services performed under this agreement will be made upon completion of each 50 hours of such remaining services, or the balance if less
than 50 hours, with final payment upon fulfillment of all services covered by this agreement.
5. As a basic requirement for eligibility to receive this work-study allowance, a student must be enrolled in a program of rehabilitation,
education, or training under laws administered by VA at a rate equal to at least three-quarters of that required of a full-time student. By
signing this agreement, I certify that I will meet this requirement. In the event I cease to be at least a three-quarter-time student or terminate
school attendance before completing this agreement, I agree to immediately provide written notice of that fact to VA. For purposes of this
agreement, terminating school attendance includes failing to enroll (or reenroll) for any regularly scheduled semester, quarter, or term of the
ordinary school year or any session of a summer term during the agreement period on which performance of work-study is based.
6. Unless VA directs otherwise, upon my reduction in training time or termination of school attendance as described in paragraph 5, I will
no longer be entitled to perform and will cease performing services under this agreement, and I will reimburse or return to VA any payment
made to me as payment for services after the date of such reduction or termination. If I reduce my training time below three-quarter-time
but remain in attendance, VA, in its sole discretion, may permit me to complete this agreement. However, if I terminate school attendance,
VA, in its sole discretion, may approve my further performance under this agreement only to the extent of those hours of service obligation
for which I received an advance payment. In either case, VA will notify me in writing of its approval of my continued performance.
7. I may terminate this agreement at any time after performing the hours of obligated services for which I received an advance payment by
sending written notice to VA, and VA may terminate this agreement for cause by furnishing written notice to me. Otherwise, this agreement
will terminate on the ending date of the specified agreement period, or earlier if I cease to meet the minimum training-time requirement or
terminate my school attendance before that date (see paragraphs 5 and 6, above).
8. Any amount of work-study allowance paid to me for which I fail to satisfactorily perform equivalent hours of service in accordance with
the terms of this agreement shall be declared an overpayment for which I shall be liable to the United States. Any such overpayment shall,
unless waived by VA, be recovered in the same manner as any other debt due the United States.
9. This agreement, entered into under the authority of section 3485 of title 38, United States Code, shall become effective upon its
acceptance by a duly authorized officer of VA.

AGREED TO:
SIGNATURE OF STUDENT

ACCEPTED BY:
DATE SIGNED

CURRENT MAILING ADDRESS OF STUDENT (Include No. and street or rural
route, city, State and ZIP Code)

VA FORM
MAR 2009

22-8692

SIGNATURE OF VA OFFICIAL

DATE SIGNED

PERMANENT MAILING ADDRESS OF STUDENT, IF DIFFERENT (Include No.
and street or rural route, city, State and ZIP Code)

EXISTING STOCKS OF VA FORM 22-8692, NOV 2005,
WILL BE USED.

FINANCE COPY 1

OMB Approved No. 2900-0209
Respondent Burden: 5 minutes

STUDENT WORK-STUDY AGREEMENT (ADVANCE PAYMENT)
VA FILE NUMBER:

AGREEMENT NUMBER:

PRIVACY ACT INFORMATION: VA will not disclose information collected by this information collection to any source other than what has been authorized by the Privacy Act of 1974 or Title 38 Code of
Federal Regulations 1.576 for routine uses as identified in VA’s system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation Records - VA as published in the Federal
Register at http://www.rms.oit.va.gov/SOR_Records/58VA21_22.asp. An example of a routine use allows VA to send 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 claims 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. Your obligation to respond is "required to obtain or retain benefits." We cannot pay you any VA work-study benefits until we
receive this information (38 U.S.C. 3485). Your responses are 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 acceptance of the VA work-study terms shown on this information collection. Title 38 United States Code allows us to ask for this
information. We estimate that you will need an average of 5 minutes to review the instructions, find the information and complete the form. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is 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 information collection.

NOTE: VA will complete the hourly rate item below with the federal minimum wage or your State minimum wage rate, whichever is greater. If you have any questions
concerning this hourly rate, contact your nearest VA office at 1-800-827-1000.

I,
(student), agree to perform
hours of service for the Department of Veterans Affairs (VA) during the period
starting on or about
and ending no later than
(agreement period), in consideration of which VA agrees to pay me a total work-study allowance of $
, subject to
the following terms, conditions and representations:
1. VA will designate and assign the services to be performed by me at various times during the agreement period and my performance will
be subject to VA supervision.
2. While performing such services, I (a) will not be considered an employee of the United States for the purpose of laws administered by the
Office of Personnel Management, but I will be considered such an employee for the purpose of receiving benefits under the provisions of
chapter 81 of title 5, U.S.C. (Compensation for Work Injuries); (b) will not receive or accept compensation from any other source for the
same hours of work performed under this agreement with the following exceptions: (1) If I am attending a college or university, I can
receive from that institution the difference between what the VA pays and the amount that the institution would otherwise pay to work-study
students performing similar services and (2) payment from an AmeriCorps Education Award; and (c) will not disclose to anyone any
information contained in VA files, records, reports, and other documents made available to me while performing such services except as
provided by the Privacy Act of 1974 (5 U.S.C. 552a), pertinent provisions of title 38, U.S.C., and supplementary regulations.
3. In return for my services under this agreement, VA will pay me a work-study allowance at the rate of $
for each hour of service I
satisfactorily perform under this agreement. (In no event may I perform more hours of service than the product of 25 times the number of
weeks in my actual period(s) of enrollment during the agreement period.)
4. Upon VA acceptance of this agreement, VA will advance me the lesser or either forty percent (40%) of the total amount of the work-study
allowance under this agreement or the amount payable for the first 50 hours of service to be performed. Not more than one advance payment
may be made in any school term (or four month period if my course is not organized on a term basis). Payment for any remaining hours of
services performed under this agreement will be made upon completion of each 50 hours of such remaining services, or the balance if less
than 50 hours, with final payment upon fulfillment of all services covered by this agreement.
5. As a basic requirement for eligibility to receive this work-study allowance, a student must be enrolled in a program of rehabilitation,
education, or training under laws administered by VA at a rate equal to at least three-quarters of that required of a full-time student. By
signing this agreement, I certify that I will meet this requirement. In the event I cease to be at least a three-quarter-time student or terminate
school attendance before completing this agreement, I agree to immediately provide written notice of that fact to VA. For purposes of this
agreement, terminating school attendance includes failing to enroll (or reenroll) for any regularly scheduled semester, quarter, or term of the
ordinary school year or any session of a summer term during the agreement period on which performance of work-study is based.
6. Unless VA directs otherwise, upon my reduction in training time or termination of school attendance as described in paragraph 5, I will
no longer be entitled to perform and will cease performing services under this agreement, and I will reimburse or return to VA any payment
made to me as payment for services after the date of such reduction or termination. If I reduce my training time below three-quarter-time
but remain in attendance, VA, in its sole discretion, may permit me to complete this agreement. However, if I terminate school attendance,
VA, in its sole discretion, may approve my further performance under this agreement only to the extent of those hours of service obligation
for which I received an advance payment. In either case, VA will notify me in writing of its approval of my continued performance.
7. I may terminate this agreement at any time after performing the hours of obligated services for which I received an advance payment by
sending written notice to VA, and VA may terminate this agreement for cause by furnishing written notice to me. Otherwise, this agreement
will terminate on the ending date of the specified agreement period, or earlier if I cease to meet the minimum training-time requirement or
terminate my school attendance before that date (see paragraphs 5 and 6, above).
8. Any amount of work-study allowance paid to me for which I fail to satisfactorily perform equivalent hours of service in accordance with
the terms of this agreement shall be declared an overpayment for which I shall be liable to the United States. Any such overpayment shall,
unless waived by VA, be recovered in the same manner as any other debt due the United States.
9. This agreement, entered into under the authority of section 3485 of title 38, United States Code, shall become effective upon its
acceptance by a duly authorized officer of VA.

AGREED TO:
SIGNATURE OF STUDENT

ACCEPTED BY:
DATE SIGNED

CURRENT MAILING ADDRESS OF STUDENT (Include No. and street or rural
route, city, State and ZIP Code)

VA FORM
MAR 2009

22-8692

SIGNATURE OF VA OFFICIAL

DATE SIGNED

PERMANENT MAILING ADDRESS OF STUDENT, IF DIFFERENT (Include No.
and street or rural route, city, State and ZIP Code)

EXISTING STOCKS OF VA FORM 22-8692, NOV 2005,
WILL BE USED.

STUDENT COPY 2

OMB Approved No. 2900-0209
Respondent Burden: 5 minutes

STUDENT WORK-STUDY AGREEMENT (ADVANCE PAYMENT)
VA FILE NUMBER:

AGREEMENT NUMBER:

PRIVACY ACT INFORMATION: VA will not disclose information collected by this information collection to any source other than what has been authorized by the Privacy Act of 1974 or Title 38 Code of
Federal Regulations 1.576 for routine uses as identified in VA’s system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation Records - VA as published in the Federal
Register at http://www.rms.oit.va.gov/SOR_Records/58VA21_22.asp. An example of a routine use allows VA to send 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 claims 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. Your obligation to respond is "required to obtain or retain benefits." We cannot pay you any VA work-study benefits until we
receive this information (38 U.S.C. 3485). Your responses are 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 acceptance of the VA work-study terms shown on this information collection. Title 38 United States Code allows us to ask for this
information. We estimate that you will need an average of 5 minutes to review the instructions, find the information and complete the form. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is 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 information collection.

NOTE: VA will complete the hourly rate item below with the federal minimum wage or your State minimum wage rate, whichever is greater. If you have any questions
concerning this hourly rate, contact your nearest VA office at 1-800-827-1000.

I,
(student), agree to perform
hours of service for the Department of Veterans Affairs (VA) during the period
starting on or about
and ending no later than
(agreement period), in consideration of which VA agrees to pay me a total work-study allowance of $
, subject to
the following terms, conditions and representations:
1. VA will designate and assign the services to be performed by me at various times during the agreement period and my performance will
be subject to VA supervision.
2. While performing such services, I (a) will not be considered an employee of the United States for the purpose of laws administered by the
Office of Personnel Management, but I will be considered such an employee for the purpose of receiving benefits under the provisions of
chapter 81 of title 5, U.S.C. (Compensation for Work Injuries); (b) will not receive or accept compensation from any other source for the
same hours of work performed under this agreement with the following exceptions: (1) If I am attending a college or university, I can
receive from that institution the difference between what the VA pays and the amount that the institution would otherwise pay to work-study
students performing similar services and (2) payment from an AmeriCorps Education Award; and (c) will not disclose to anyone any
information contained in VA files, records, reports, and other documents made available to me while performing such services except as
provided by the Privacy Act of 1974 (5 U.S.C. 552a), pertinent provisions of title 38, U.S.C., and supplementary regulations.
3. In return for my services under this agreement, VA will pay me a work-study allowance at the rate of $
for each hour of service I
satisfactorily perform under this agreement. (In no event may I perform more hours of service than the product of 25 times the number of
weeks in my actual period(s) of enrollment during the agreement period.)
4. Upon VA acceptance of this agreement, VA will advance me the lesser or either forty percent (40%) of the total amount of the work-study
allowance under this agreement or the amount payable for the first 50 hours of service to be performed. Not more than one advance payment
may be made in any school term (or four month period if my course is not organized on a term basis). Payment for any remaining hours of
services performed under this agreement will be made upon completion of each 50 hours of such remaining services, or the balance if less
than 50 hours, with final payment upon fulfillment of all services covered by this agreement.
5. As a basic requirement for eligibility to receive this work-study allowance, a student must be enrolled in a program of rehabilitation,
education, or training under laws administered by VA at a rate equal to at least three-quarters of that required of a full-time student. By
signing this agreement, I certify that I will meet this requirement. In the event I cease to be at least a three-quarter-time student or terminate
school attendance before completing this agreement, I agree to immediately provide written notice of that fact to VA. For purposes of this
agreement, terminating school attendance includes failing to enroll (or reenroll) for any regularly scheduled semester, quarter, or term of the
ordinary school year or any session of a summer term during the agreement period on which performance of work-study is based.
6. Unless VA directs otherwise, upon my reduction in training time or termination of school attendance as described in paragraph 5, I will
no longer be entitled to perform and will cease performing services under this agreement, and I will reimburse or return to VA any payment
made to me as payment for services after the date of such reduction or termination. If I reduce my training time below three-quarter-time
but remain in attendance, VA, in its sole discretion, may permit me to complete this agreement. However, if I terminate school attendance,
VA, in its sole discretion, may approve my further performance under this agreement only to the extent of those hours of service obligation
for which I received an advance payment. In either case, VA will notify me in writing of its approval of my continued performance.
7. I may terminate this agreement at any time after performing the hours of obligated services for which I received an advance payment by
sending written notice to VA, and VA may terminate this agreement for cause by furnishing written notice to me. Otherwise, this agreement
will terminate on the ending date of the specified agreement period, or earlier if I cease to meet the minimum training-time requirement or
terminate my school attendance before that date (see paragraphs 5 and 6, above).
8. Any amount of work-study allowance paid to me for which I fail to satisfactorily perform equivalent hours of service in accordance with
the terms of this agreement shall be declared an overpayment for which I shall be liable to the United States. Any such overpayment shall,
unless waived by VA, be recovered in the same manner as any other debt due the United States.
9. This agreement, entered into under the authority of section 3485 of title 38, United States Code, shall become effective upon its
acceptance by a duly authorized officer of VA.

AGREED TO:
SIGNATURE OF STUDENT

ACCEPTED BY:
DATE SIGNED

CURRENT MAILING ADDRESS OF STUDENT (Include No. and street or rural
route, city, State and ZIP Code)

VA FORM
MAR 2009

22-8692

SIGNATURE OF VA OFFICIAL

DATE SIGNED

PERMANENT MAILING ADDRESS OF STUDENT, IF DIFFERENT (Include No.
and street or rural route, city, State and ZIP Code)

EXISTING STOCKS OF VA FORM 22-8692, NOV 2005,
WILL BE USED.

PERSONNEL COPY 3

OMB Approved No. 2900-0209
Respondent Burden: 5 minutes

STUDENT WORK-STUDY AGREEMENT (ADVANCE PAYMENT)
VA FILE NUMBER:

AGREEMENT NUMBER:

PRIVACY ACT INFORMATION: VA will not disclose information collected by this information collection to any source other than what has been authorized by the Privacy Act of 1974 or Title 38 Code of
Federal Regulations 1.576 for routine uses as identified in VA’s system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation Records - VA as published in the Federal
Register at http://www.rms.oit.va.gov/SOR_Records/58VA21_22.asp. An example of a routine use allows VA to send 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 claims 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. Your obligation to respond is "required to obtain or retain benefits." We cannot pay you any VA work-study benefits until we
receive this information (38 U.S.C. 3485). Your responses are 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 acceptance of the VA work-study terms shown on this information collection. Title 38 United States Code allows us to ask for this
information. We estimate that you will need an average of 5 minutes to review the instructions, find the information and complete the form. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is 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 information collection.

NOTE: VA will complete the hourly rate item below with the federal minimum wage or your State minimum wage rate, whichever is greater. If you have any questions
concerning this hourly rate, contact your nearest VA office at 1-800-827-1000.

I,
(student), agree to perform
hours of service for the Department of Veterans Affairs (VA) during the period
starting on or about
and ending no later than
(agreement period), in consideration of which VA agrees to pay me a total work-study allowance of $
, subject to
the following terms, conditions and representations:
1. VA will designate and assign the services to be performed by me at various times during the agreement period and my performance will
be subject to VA supervision.
2. While performing such services, I (a) will not be considered an employee of the United States for the purpose of laws administered by the
Office of Personnel Management, but I will be considered such an employee for the purpose of receiving benefits under the provisions of
chapter 81 of title 5, U.S.C. (Compensation for Work Injuries); (b) will not receive or accept compensation from any other source for the
same hours of work performed under this agreement with the following exceptions: (1) If I am attending a college or university, I can
receive from that institution the difference between what the VA pays and the amount that the institution would otherwise pay to work-study
students performing similar services and (2) payment from an AmeriCorps Education Award; and (c) will not disclose to anyone any
information contained in VA files, records, reports, and other documents made available to me while performing such services except as
provided by the Privacy Act of 1974 (5 U.S.C. 552a), pertinent provisions of title 38, U.S.C., and supplementary regulations.
3. In return for my services under this agreement, VA will pay me a work-study allowance at the rate of $
for each hour of service I
satisfactorily perform under this agreement. (In no event may I perform more hours of service than the product of 25 times the number of
weeks in my actual period(s) of enrollment during the agreement period.)
4. Upon VA acceptance of this agreement, VA will advance me the lesser or either forty percent (40%) of the total amount of the work-study
allowance under this agreement or the amount payable for the first 50 hours of service to be performed. Not more than one advance payment
may be made in any school term (or four month period if my course is not organized on a term basis). Payment for any remaining hours of
services performed under this agreement will be made upon completion of each 50 hours of such remaining services, or the balance if less
than 50 hours, with final payment upon fulfillment of all services covered by this agreement.
5. As a basic requirement for eligibility to receive this work-study allowance, a student must be enrolled in a program of rehabilitation,
education, or training under laws administered by VA at a rate equal to at least three-quarters of that required of a full-time student. By
signing this agreement, I certify that I will meet this requirement. In the event I cease to be at least a three-quarter-time student or terminate
school attendance before completing this agreement, I agree to immediately provide written notice of that fact to VA. For purposes of this
agreement, terminating school attendance includes failing to enroll (or reenroll) for any regularly scheduled semester, quarter, or term of the
ordinary school year or any session of a summer term during the agreement period on which performance of work-study is based.
6. Unless VA directs otherwise, upon my reduction in training time or termination of school attendance as described in paragraph 5, I will
no longer be entitled to perform and will cease performing services under this agreement, and I will reimburse or return to VA any payment
made to me as payment for services after the date of such reduction or termination. If I reduce my training time below three-quarter-time
but remain in attendance, VA, in its sole discretion, may permit me to complete this agreement. However, if I terminate school attendance,
VA, in its sole discretion, may approve my further performance under this agreement only to the extent of those hours of service obligation
for which I received an advance payment. In either case, VA will notify me in writing of its approval of my continued performance.
7. I may terminate this agreement at any time after performing the hours of obligated services for which I received an advance payment by
sending written notice to VA, and VA may terminate this agreement for cause by furnishing written notice to me. Otherwise, this agreement
will terminate on the ending date of the specified agreement period, or earlier if I cease to meet the minimum training-time requirement or
terminate my school attendance before that date (see paragraphs 5 and 6, above).
8. Any amount of work-study allowance paid to me for which I fail to satisfactorily perform equivalent hours of service in accordance with
the terms of this agreement shall be declared an overpayment for which I shall be liable to the United States. Any such overpayment shall,
unless waived by VA, be recovered in the same manner as any other debt due the United States.
9. This agreement, entered into under the authority of section 3485 of title 38, United States Code, shall become effective upon its
acceptance by a duly authorized officer of VA.

AGREED TO:
SIGNATURE OF STUDENT

ACCEPTED BY:
DATE SIGNED

CURRENT MAILING ADDRESS OF STUDENT (Include No. and street or rural
route, city, State and ZIP Code)

VA FORM
MAR 2009

22-8692

SIGNATURE OF VA OFFICIAL

DATE SIGNED

PERMANENT MAILING ADDRESS OF STUDENT, IF DIFFERENT (Include No.
and street or rural route, city, State and ZIP Code)

EXISTING STOCKS OF VA FORM 22-8692, NOV 2005,
WILL BE USED.

SERVICE COPY 4