Form VA Form 22-1919 VA Form 22-1919 Conflicting Interests Certification for Proprietary Scho

OMB Control No. 2900-0657
Respondent Burden: 10 Minutes
Expiration Date: XXXXXXXX

CONFLICTING INTERESTS CERTIFICATION FOR PROPRIETARY SCHOOLS
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, 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 education benefits to any person training at your school 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 approve courses at your school for VA purposes and pay education benefits to trainees at your
facility. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 10 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 (1-888-442-4551) to get
information on where to send comments or suggestions about this form.
NAME AND ADDRESS OF INSTITUTION

PURPOSE: This form informs individuals that the law has restrictions concerning any potential conflict of interest. (See
certifications (1) and (2) below).
(1) PROPRIETARY PROFIT SCHOOLS ONLY
Title 38 U.S.C. 3683 prohibits employees of the Department of Veterans Affairs (VA) and the State approving agency (SAA) from
owning any interest in an educational institution operated for profit. In addition, the law prohibits these employees from receiving
any wages, salary, dividends, profits, gifts, or services from private profit schools. These provisions may be waived if VA determines
that no detriment will result to the government, or to veterans or eligible persons. Please list below those VA and
SAA employees known by you who may have a potential conflict of interest under this provision. If there are none, please enter the
word "none."
NAME AND TITLE OF EMPLOYEES(S)

DESCRIPTION OF ASSOCIATION WITH SCHOOL

(2) ALL PROPRIETARY SCHOOLS
Title 38 C.F.R. 21.4202(c), 21.5200(c), 21.7122(e)(6), and 21.7622(f)(4)(iv) prohibit the payment of educational assistance to any
veteran or eligible person based on an enrollment in any proprietary school of which the veteran or eligible person is an official
authorized to sign certificates of enrollment or verifications/certifications of attendance, or is an owner or an officer. Please list
below the names and VA file numbers (claim or Social Security Numbers) of any certifying officials, owners, or officers of your
school who receive VA educational assistance based on an enrollment in your school. If there is none, please enter the word "none."
NAME AND TITLE OF EMPLOYEE(S)

VA FILE NUMBER

DATES OF ENROLLMENT WITH YOUR SCHOOL
FROM

TO

CERTIFICATION: I DO HEREBY CERTIFY that the entries above are true and correct to the best of my knowledge. I agree to
immediately notify VA of any potential violations of the above prohibitions.
SIGNATURE OF PRESIDENT OR CHIEF ADMINISTRATIVE OFFICIAL OF SCHOOL

VA FORM
XXX 2014

22-1919

TITLE

SUPERSEDES VA FORM 22-1919, OCT 2008,
WILL BE USED.

DATE