Form 22-6553b-1 Certification of Lessons Completed

OMB Control No. 2900-0353
Respondent Burden: 10 Minutes
Expiration Date: XXXX

CERTIFICATE OF LESSONS
COMPLETED

FOR VA USE ONLY
VA FILE NUMBER

FACILITY CODE

PAYEE

TYPE TRAINING

NUMBER LESSONS AUTHORIZED

IMPORTANT
1. Read all instructions before completing this form.
2. If this form is damaged or lost, ask VA for another form.
(Call 1-888-GI-BILL-1 (1-888-442-4551)). (Call 711, Federal Relay, if
you use the Telecommunications Device for the Deaf (TDD)).
NOTE - PLEASE READ THE PRIVACY ACT INFORMATION AND RESPONDENT BURDEN ON THE REVERSE BEFORE COMPLETING THIS FORM.

INSTRUCTIONS TO STUDENT
IF YOU ARE ENROLLED AND STILL PURSUING YOUR COURSE - COMPLETE THIS FORM ONLY if you are due payment for one or more lessons
completed and sent to the school through the last date shown in Item 2. (We will send you a new form at the end of the next quarter.) To receive payment, check BOX A
IN ITEM 1. Then enter in Item 4A the total number of lessons completed and sent to the school since you started this course. VA bases payments on the number of
lessons completed by you and serviced by the school. If you have completed additional lessons, but your school has not yet serviced these additional lessons, VA will
pay for those lessons at the end of the quarter in which your school services those lessons.
IF YOU ARE NO LONGER ENROLLED - Check the applicable box, B or C, in Item 1 if you completed or terminated your course. Then, enter in Item 4A the total
number of lessons that you have completed and sent to the school.
BEFORE SENDING THE FORM TO YOUR SCHOOL - Sign and date this form in Items 8A and 8B. Place your telephone number in Item 8C. If the school has
furnished you with an identification number, place that ID number in Item 4B.
WHERE TO SEND THE FORM - Send the completed form promptly to the school for their certification. Your payment will be issued after receipt of the school's
certification.
ADDRESS CHANGE - If you are changing your address permanently, neatly line out your address and print your new address in the remaining space. Be sure to show
your ZIP Code.

INSTRUCTIONS TO SCHOOL

IF STUDENT IS STILL ENROLLED AND PURSUING THE COURSE - Check the "YES" block in Item 3. In Item 6, enter the total number of lessons serviced
from the date the student started this course through the ending date to be certified in Item 2.
IF STUDENT IS NO LONGER ENROLLED - Check "NO" block in Item 3. Enter the date the last lesson was serviced in Item 5. In Item 6, enter the total number of
lessons you have serviced through the date shown in Item 5.
REMARKS - Report any exception to the student's certification in Item 7, Remarks.
BEFORE SENDING THE FORM TO VA - Sign and date the certification in Items 9A and 9B. Send the completed form to the VA office shown above.
1. COURSE PARTICIPATION (Check applicable box)

2. PERIOD TO BE CERTIFIED

3. IS STUDENT STILL ENROLLED

A.

I WAS PURSUING THE COURSE APPROVED BY VA
FOR THE PERIOD SHOWN IN ITEM 2

YES

B.

I COMPLETED MY COURSE C.

NO (If "No," complete Item 5)

4A. TOTAL NUMBER OF LESSONS
COMPLETED TO DATE

I TERMINATED MY COURSE
4B. SCHOOL IDENTIFICATION
NUMBER

5. IF TERMINATED OR COMPLETED ENTER
DATE LAST LESSON SERVED

6. TOTAL NUMBER OF LESSONS
SERVICED TO DATE

7. REMARKS

I CERTIFY THAT the above entries are true and, if applicable, the 85-15% ratio requirements were met for this student's course of study.
PENALTY - Willful false reports concerning benefits payable by VA may result in fines or imprisonment or both.
8A. SIGNATURE OF STUDENT

8B. DATE

9A. SIGNATURE AND TITLE OF CERTIFYING OFFICIAL

VA FORM
XXXX

22-6553b-1

8C. TELEPHONE NO. (Including Area Code)
9B. DATE SIGNED

SUPERSEDES VA FORM 22-6553b-1, JUL 2012,
WHICH WILL NOT BE USED.

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 1.576 for routine uses (i.e., 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 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. VA cannot determine your eligibility for further
educational benefits and the proper rate payable unless this form is completed and filed as required by existing law and regulation
(38 U.S.C. 3680). While you are not required to respond, we cannot pay you any further education benefits until we receive this
information. Your responses are confidential (38 U.S.C. 5701). The information you send may be verified through computer matching
programs with other agencies.
RESPONDENT BURDEN: We need this information to reimburse you for those correspondence course lessons you completed and
were serviced by your correspondence school. 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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. 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. (Call 711, Federal Relay, if you use the Telecommunications
Device for the Deaf (TDD)).

VA FORM 22-6553b-1, XXXX