Form VA Form 22-1999c VA Form 22-1999c Certificate of Affirmation of Enrollment Agreement - Cor

OMB Control No. 2900-0576
Respondent Burden: 3 Minutes
Expiration Date: XXXXXXXX

CERTIFICATE OF AFFIRMATION OF ENROLLMENT
AGREEMENT- CORRESPONDENCE COURSE
1. FIRST NAME-MIDDLE INITIAL-LAST NAME OF ELIGIBLE PERSON

3. NAME OF COURSE

4. DATE ENROLLMENT
AGREEMENT SIGNED

2. VA FILE NO.

5. NAME AND ADDRESS OF SCHOOL

PURPOSE OF THE AFFIRMATION PROVISION OF LAW
To provide you time (no less than five full days following your signing of an enrollment agreement) during
which you can reflect on your decision to enroll in a correspondence course and determine if such
correspondence course is suitable to your abilities and interests. The Correspondence School Agreement you
have signed is not effective unless you complete this form and return it to the school.
AFFIRMATION PROCEDURE:
A. Decision not to Affirm - If you decide not to affirm the Correspondence School Agreement you have signed,
do not sign this form. Destroy it. Additionally, you may notify the institution, at any time, of your decision not
to affirm the enrollment agreement. The institution, thereupon, without imposing any penalty or fee, shall make
full refund of all amounts paid.
B. Decision to Affirm - If you decide to affirm the Correspondence School Agreement you have signed, you
may affirm only after the expiration of 5 full days after the day on which the agreement was signed. For
example, if the contract was signed on the 1st day of a month, you must sign and date this affirmation
certification form on or after the 7th day.
VA WILL NOT ACCEPT ANY AFFIRMATION YOU SIGN BEFORE THE 7TH DAY.
VA WILL NOT PAY FOR LESSONS THAT YOU COMPLETE AND THE SCHOOL SERVICES BEFORE
THE PROPER AFFIRMATION DATE.
TO AFFIRM, READ THE FOLLOWING PARAGRAPH AND COMPLETE ITEMS 6 AND 7 BELOW:
I have read and I understand the enrollment agreement that I entered into with the above named school on the
date indicated in Item 4. By signing this form, I affirm such enrollment agreement and certify, under penalty of
law, that I have not signed this affirmation certificate until after the expiration of 5 full days after the date I
signed the aforesaid enrollment agreement.
(SUBMIT WITH ENROLLMENT CERTIFICATION)

INSTRUCTION TO CLAIMANT: After completion of Items 6 and 7 on or after the 7th day, return VA COPY
1 and SCHOOL COPY 2 of this form to the school identified in Item 5.
INSTRUCTION TO SCHOOL: Once the student submits VA COPY 1 and SCHOOL COPY 2 of
VA Form 22-1999c to your facility, the school should submit VA COPY 1 of VA Form 22-1999c
(Certificate of Affirmation of Enrollment Agreement - Correspondence Course) and VA Form 22-1999
(Enrollment Certification) to the Department of Veterans Affairs.
6. DATE SIGNED

VA FORM
XXX 2014

22-1999c

7. SIGNATURE OF ELIGIBLE PERSON

SUPERSEDES VA FORM 22-1999c, NOV 2008,
WHICH WILL NOT BE USED.

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 Title 38, Code of Federal Regulations 1.576 for routine uses
as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational
Rehabilitation and Employment Records - VA, published in the Federal Register. 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 education benefits for taking a correspondence course until we receive this information
(38 U.S.C. 3686(b)). 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 eligibility for education benefits based on a
correspondence course and the proper amount payable for that correspondence course. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 3 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-888-GI-BILL-1 (1-800-442-4551) to
get information on where to send comments or suggestions about this form.

VA FORM 22-1999c, XXX 2014