VA Form 21-8938-1 Student Beneficiary Report - REPS (Restored Entitlement

OMB Control No. 2900-0399
Respondent Burden: 20 Minutes
Expiration Date: XX/XX/XXXX

STUDENT BENEFICIARY REPORT - REPS
(RESTORED ENTITLEMENT PROGRAM FOR SURVIVORS)
PRIVACY ACT NOTICE: The 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 5, Code of Federal Regulations 1.526 for routine uses (i.e., (Routine Uses 1 through 63) as identified in the VA system of records,
58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation Records - VA, and published in the Federal Register. Your obligation to
respond is required to obtain or retain benefits. Giving us your SSN account information is voluntary. No benefits may be granted unless this form is completed
fully as required by law (38 U.S.C. 5101). Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual
benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and
still in effect.
RESPONDENT BURDEN: We need this information in order to determine your continued eligibility for REPS payments as a student beneficiary. Title 38,
United States Code, allows us to ask for this information. We estimate that you will need an average of 20 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 1-800-827-1000 to get information on where to send comments or suggestions about this form.

SECTION I - STUDENT IDENTIFICATION

1A. NAME AND ADDRESS OF STUDENT (First, middle, last name)

1B. VETERAN/WAGE EARNER'S SOCIAL SECURITY NO.

1C. STUDENT'S SOCIAL SECURITY NO.
2. PERIOD OF ATTENDANCE
A. BEGINNING DATE
B. ENDING DATE
(Month, day, year)
(Month, day, year)

(If different from above, furnish current address)
INSTRUCTIONS: STUDENTS - You must complete Section II, Student Certification, and have a school official verify your attendance. SCHOOL
OFFICIALS - Please complete Section III, School Official Certification, and return it promptly as failure to do so will result in suspension of the student's
benefit payment. This form should be returned to the VA REGIONAL OFFICE (331/21Q), 400 SOUTH 18TH STREET, ST. LOUIS, MO 63103-2271.
(NOTE: DO NOT USE "NA" OR "UNKNOWN" IN ITEMS REQUIRING COMPLETION.) IMPORTANT - THIS FORM SHOULD NOT BE RETURNED
TO THE STUDENT.

SECTION II - STUDENT CERTIFICATION

3. NAME OF SCHOOL YOU ATTENDED
DURING PERIOD(S) SHOWN IN ITEM 2

4A. HAVE YOU ATTENDED SCHOOL ON A FULL-TIME BASIS
5. LIST DATES OF FULL-TIME
FOR PERIOD SHOWN IN ITEM 2?
ATTENDANCE IF DIFFERENT
FROM ITEM 2 (Month, day, year)
YES
NO (If "No," complete Item 5)
4B. TYPE OF DEGREE
GRAD
UNDERGRAD
OTHER
6. WILL YOU CONTINUE SCHOOL ON A FULL-TIME BASIS
7. DATES OF YOUR NEXT SCHOOL YEAR
AFTER THE END OF THE PERIOD SHOWN IN ITEM 2?
A. BEGINNING DATE (Month, day, year)
B. ENDING DATE (Month, day, year)
YES
NO (If "Yes," complete Item 7)
8A. WILL YOU ATTEND THE SCHOOL SHOWN IN ITEM 3? 8B. NAME AND ADDRESS OF NEW
SCHOOL
YES
NO (If "No," complete Items 8B thru 8D)
8D. TYPE OF DEGREE
GRAD
OTHER
UNDERGRAD
9. EARNINGS/WAGES RECEIVED FOR PRIOR
YEAR (ENTER DOLLAR AMOUNT OR "NONE")
YEAR
AMOUNT

10A. EARNINGS EXPECTED THIS YEAR
(ENTER DOLLAR AMOUNT OR "NONE")
YEAR
AMOUNT

11. HAVE YOU OR WILL YOU BE PAID BY YOUR 12A. HAVE YOU EVER BEEN MARRIED?
EMPLOYER FOR ATTENDING SCHOOL?
NO (If "Yes," complete Item 12B)
YES
NO
YES

8C. TYPE OF NEW SCHOOL
COLLEGE OR UNIVERSITY
TECHNICAL, TRADE OR VOCATIONAL
OTHER (Specify)
10B. EARNINGS EXPECTED NEXT YEAR
(ENTER DOLLAR AMOUNT OR "NONE")
YEAR
AMOUNT
12B. DATE(S) OF MARRIAGE (Month, day, year)

IMPORTANT: IT IS YOUR DUTY TO REPORT ANY CHANGE IN STATUS. You must notify the VA immediately of any change in school
enrollment, marital or work status, as benefits may be affected.
I CERTIFY THAT the previous statements are true and correct to the best of my knowledge and belief.
13A. SIGNATURE OF CLAIMANT

13C. DATE SIGNED (Month, day, year)

13B. CLAIMANT'S TELEPHONE NUMBER
(Include Area Code)

SECTION III - SCHOOL OFFICIAL CERTIFICATION

14. HAS THE STUDENT MAINTAINED
FULL-TIME STATUS BY THE SCHOOL'S
STANDARDS DURING THE ENTIRE
PERIOD SHOWN IN ITEM 2?

15A. LIST DATES OF FULL-TIME ATTENDANCE, INCLUDING LAST DATE OF FULL-TIME
ATTENDANCE WHEN A COURSE WITHDRAWAL IS INVOLVED

15B. IF TERM CLAIMED IN ITEM 7 HAS BEGUN, IS STUDENT STILL FULL-TIME?

YES
NO
16C. TYPE OF SCHOOL
COLLEGE OR
TECHNICAL, TRADE
UNIVERSITY
OR VOCATIONAL
16B. TELEPHONE NUMBER OF SCHOOL OFFICIAL 16D. TYPE OF DEGREE
(Include Area Code)
OTHER
GRAD
UNDERGRAD
YES
NO (If "No," complete Item 15)
16A. NAME OF SCHOOL

OTHER

17. ENTER CLOCK HOURS
ATTENDED PER WEEK IF NOT A
DEGREE GRANTING PROGRAM

18B. DATE SIGNED (Month, day, year)

18A. SIGNATURE AND TITLE OF SCHOOL OFFICIAL

PENALTY: The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a
material fact, knowing it to be false or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM
MAY 2014

21-8938-1

SUPERSEDES VA FORM 21-8938-1, JUN 2008,
WHICH WILL NOT BE USED.