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

(Check one)
MAILING ADDRESS OF INSTITUTION OF HIGHER LEARNING

Public IHL

Private IHL

AGREEMENT TYPE (Check one)
NEW OPEN-ENDED AGREEMENT

DATE RECEIVED
(For VA use only)

MODIFICATION TO EXISTING AGREEMENT
WITHDRAWAL OF YELLOW RIBBON AGREEMENT

NOTE: If selecting withdrawal of agreement, only the
signature of authorizing official and date are required.

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. Once this agreement is accepted by VA, it will be considered an open-ended agreement that is in effect for the upcoming
academic year and all future academic years unless VA or the Institution notifies the other party that changes are requested.
Withdrawal from the Yellow Ribbon Program or modifications to the terms of the agreement shall only be made during the open
season enrollment period, March 15 - May 15 (or the following Monday if May 15th falls on a Saturday or Sunday). Withdrawal or
modifications to the terms shall be indicated in Agreement Type above. Modifications made during the open enrollment period will
go into effect for the subsequent academic year and will be posted to our website at http://www.gibill.va.gov when the open
enrollment period ends. Please see Page 4 of this form for information about how to submit the completed form.
2. 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.
3. 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.
4. 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.
5. The IHL agrees to provide the maximum amount of contributions payable toward the net cost for each participating individual
during each term, quarter, or semester the individual is enrolled if the IHL's total contribution toward the individual's net cost for
the term, quarter, or semester does not exceed the maximum dollar amount payable during the academic year as specified in
paragraph 8 of this agreement.
6. The IHL agrees to provide contributions for each Yellow Ribbon Program participant using the following:
Direct Grant

Scholarship

Other

7. The IHL agrees to provide Yellow Ribbon Program contributions for up to _________________ eligible individuals during
the ________________ academic year and all sebsequent academic years unless VA is notified of changes during any subsequent
open-enrollment period.
8. The IHL agrees to provide Yellow Ribbon Program contributions for each participant during the academic years up to the
following amounts (fill in all applicable fields):
A. MAXIMUM NUMBER
OF STUDENTS

VA FORM
JAN 2012

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

(Attach additional listings if necessary)

22-0839

D. MAXIMUM
CONTRIBUTION
AMOUNT

C. COLLEGE OR PROFESSIONAL
SCHOOL
$
$
$
$
$
$
$
$
$
$
$
$

SUPERSEDES VA FORM 22-0839, JAN 2010,
WHICH WILL NOT BE USED.

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9. 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.
10. 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, and all subsequent academic years unless VA is notified
of changes during any subsequent open-enrollment period.
11. The terms of this agreement will be available for public viewing on VA's GI Bill website at www.GIBILL.va.gov.
12. 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 15 (or the following Monday if May 15 falls on a weekend). Late agreements
will not be accepted. The agreement, once accepted by VA, will be considered an open-ended agreement. See Page 1 for
information pertaining to modification of terms.
13. 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.
14. 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

ACCEPTED BY:

SIGNATURE OF VA OFFICIAL

VA FORM 22-0839, JAN 2012

TITLE OF AUTHORIZING OFFICIAL

TELEPHONE NUMBER

DATE SIGNED

FOR VA USE ONLY
DATE SIGNED

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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, check the type of agreement, and the category of the IHL.
Items 1-5
By signing and submitting this form to VA, the IHL agrees to adhere to the provisions listed in
Items 1-5.
Item 6
Check the appropriate boxes. 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 7
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 8. Enter the dates of the upcoming academic year (e.g., 2012-2013) for which the agreement is being
submitted. (NOTE: An academic year for VA purposes is August 1 to July 31.)
Item 8
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 unlimited.
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 - This column may be left blank, or specify the appropriate sub element
(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 unlimited.
NOTE: IHL's must complete columns A and D for each contribution listed. IHL's must also complete column B,
C, or both B and C for each contribution listed.
EXAMPLE:
A. MAXIMUM NUMBER
OF STUDENTS

10

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

Undergraduate

15
20
VA FORM 22-0839, JAN 2012

Graduate

D. MAXIMUM
CONTRIBUTION
AMOUNT

C. COLLEGE OR PROFESSIONAL
SCHOOL
$

2,000

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 9
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 wants 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. You may only include any locations/branches
that have facility codes.
NOTE: Each campus will be held to the terms specified in the agreement.
Items 10 and 11
Self-explanatory.
Item 12
Yellow Ribbon Program Agreements must be received by VA no later than May 15th (or the following Monday if
May 15th falls on a Saturday or Sunday) to be considered for participation.
Item 13
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 14
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. (Please ensure
that the information is legible.)
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. Agreements will not be processed without a valid
signature.
FORM SUBMISSION
The preferred method is via email. Confirmation of email or fax constitutes VA's receipt of the agreement and
should be maintained for the IHL's records. Only submit one signed agreement. The institution will receive an
approved agreement and accompanying letter or other related communication.
This form must 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 (223C)
810 Vermont Avenue, NW
Washington, DC 20420
If sent via email or fax, retain proof of submission (email or fax transmittal). If sent via mail return receipt
requested, retain proof of receipt.

VA FORM 22-0839, JAN 2012

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