Form 22-0810 Application for Reimbursement of National Exam Fee

OMB Control No. 2900-0706
Respondent Burden: 15 minutes
Expiration Date: XXXX

APPLICATION FOR REIMBURSEMENT OF NATIONAL EXAM FEE
(See General Information on Reverse)

Please read the Privacy Act and Respondent Burden information on the reverse before completing the form.

IMPORTANT: Complete this application to apply for reimbursement of a national exam fee (one exam per form). You must apply separately for VA
benefits if you have not already done so. (SEE REVERSE FOR INFORMATION AND INSTRUCTIONS BEFORE COMPLETING THIS FORM)

Part I - IDENTIFICATION INFORMATION

1. APPLICANT'S NAME (First, Middle Initial, Last Name)

2. APPLICANT'S ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code)

3. TELEPHONE NUMBER (Include Area Code) (Indicate hours you can be reached)
DAYTIME

4. SOCIAL SECURITY NUMBER OF APPLICANT

EVENING

5. VA FILE NUMBER (For chapter 35, enter the veteran's file number and include your suffix indicator. For chapter 30 dependent's case, enter the file number of the

person who transferred entitlement to you.)

6. VA EDUCATION INFORMATION
A. HAVE YOU PREVIOUSLY APPLIED FOR VA EDUCATION BENEFITS?

YES

(If "Yes," show the specific benefit you previously applied for in Item 6B)

NO

(If "No," you must also complete an Application for VA Education Benefits, VA Form 22-1990)

B. WHAT EDUCATION BENEFIT HAVE YOU APPLIED FOR PREVIOUSLY?

C. UNDER WHAT EDUCATION BENEFIT ARE YOU NOW APPLYING FOR EXAM FEE REIMBURSEMENT?

Post-9/11 GI Bill (Chapter 33)
Montgomery GI Bill - Active Duty Educational Assistance Program (MGIB) (Chapter 30)
Post-Vietnam Era Veterans Educational Program (VEAP) (Chapter 32)
Survivors' and Dependents' Educational Assistance Program (DEA) (Chapter 35)
Montgomery GI Bill - Selected Reserve Educational Assistance Program (MGIB-SR) (Chapter 1606)
Reserve Educational Assistance Program (REAP) (Chapter 1607)
National Call to Service (NCS)

Part II - EXAM INFORMATION (Specify each item for this exam)
10. ITEMIZE EXAM COST INCLUDING FEES (Attach receipt)

7. NAME OF EXAM
8. ORGANIZATION GIVING EXAM (Indicate if taken online)
9. DATE EXAM TAKEN
11. REMARKS (Optional)

Part III - CERTIFICATION AND SIGNATURE OF APPLICANT

I CERTIFY THAT the information above is true and correct to the best of my knowledge and belief.

PENALTY - Willfully false statements as to a material fact in a claim for education benefits payable by VA may result in a fine, imprisonment, or both.
12. SIGNATURE OF APPLICANT (Do NOT print)

13. DATE SIGNED

IMPORTANT - Please return this form to the VA Regional Processing Office that handles your area (see the VA Regional Processing Office
addresses on the Information and Instructions page of this form.) You do not normally have to submit a receipt or proof of payment for the exam;
however, a receipt is required for DSSD and LC-PA exams and in certain situations for CLEP, MAT, and PCAT exams. Please visit www.benefits.va.
gov/gibill/national_testing for more information. Also, VA will request a copy of your exam results only if needed.
VA FORM
XXXX

22-0810

SUPERSEDES VA FORM 22-0810, JUL 2012,
WHICH WILL NOT BE USED.

INFORMATION AND INSTRUCTIONS
(The items that are considered self-explanatory are not included in these instructions)
ITEM 5. If you (or the veteran or service person) were previously assigned an 8-digit file number, enter this number.
ITEM 6A. If you have not previously applied for VA education benefits, go to www.gibill.va.gov and click on "Education Benefits" then click on
"How to Apply for Benefits."
ITEM 7. Write the complete name of the exam that you took. Show exam information for only one exam on any one application.
ITEM 8. Write the complete name of the organization that administered the national exam you took.
ITEM 9. Show the date you took the national exam.
ITEM 10. Enter the cost of the exam you took, including any required fees. (We can only reimburse you for required exam fees.) We have no authority
to reimburse you for any optional costs related to the examination process. Exam fees that VA will reimburse include "registration fees," fees for
specialized exams, and administrative fees such as a proctoring fee. Fees that VA has no authority to reimburse include fees to take pre-exams (such as
Kaplan exams), fees to receive scores quickly, or other costs or fees for optional items that are not required to take an approved exam.
ITEM 11. Use the space in this item to provide information that does not fit elsewhere on this form or that will help VA process your claim. Refer to
other item numbers on this form to help us match your answers to the correct questions. If more space is needed, please attach separate sheets of paper.
Be sure to place your name and VA file number or social security number on each additional page.
ITEM 12 AND 13. Sign and date the form.
MORE HELP: Our education internet site (www.gibill.va.gov) is available to help you, even after normal business hours. If you need help in completing
this application, call VA TOLL-FREE at 1-888-GI-BILL-1 (1-888-442-4551). If you use the Telecommunications Device for the Deaf (TDD), the
Federal Relay number is 711.
HOW TO FILE YOUR CLAIM. Send the completed application to the Regional Processing Office in the region of your home address. Use the
addresses shown below.
EASTERN REGION:
VA Regional Office
P. O. Box 4616
Buffalo, NY 14240-4616

CT
MD
NY
VA

Serves the following states:
DE
DC
NH
MA
PA
RI

Foreign Schools

CENTRAL REGION:
VA Regional Office
P. O. Box 66830
ST. LOUIS, MO 63166-6830

ME
NJ
VT

CO
KS
MO
OH
WI

WESTERN REGION:
VA Regional Office
P. O. Box 8888
Muskogee, OK 74402-8888

AK
CA
MS
OR

Philippines

Serves the following states:
AL
AR
HI
ID
NM
NV
TX
UT
Guam

APO/FPO AP

Serves the following states:
IA
IL
KY
MI
MT
NE
TN
SD
WY

IN
MN
ND
WV

SOUTHERN REGION:
VA Regional Office
P. O. Box 100022
Decatur, GA 30031-7022

AZ
LA
OK
WA

FL
PR

Serves the following states:
GA
NC

US Virgin Islands

APO/FPO AA

SC

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, section 1.576 for routine uses (e.g., VA sends 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) as identified in VA's system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records VA, published in the Federal Register. Your obligation to respond is voluntary. While you do not have to respond, VA cannot process your claim for reimbursement of national test fees unless the
information is furnished as required by existing law (38 U.S.C. 3471). The responses you submit are considered 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 reimbursement of national test fees. We cannot reimburse you for any test fees until we receive this
information (38 U.S.C. 5101). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 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 http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-888GI-BILL-1 (1-888-442-4551) to get information on where to send comments or suggestions about this information collection.
VA FORM 22-0810, XXXX