Form 22-6553d-1 Monthly Certification of On-The-Job and Apprenticeship T

OMB Approved No. 2900-0178
Respondent Burden: 10 Minutes
Expiration Date: 11/30/2021
REGIONAL PROCESSING OFFICE (RPO) NAME AND ADDRESS OR FAX NUMBER
(See RPO listing on reverse)

MONTHLY CERTIFICATION OF ON-THE-JOB
AND APPRENTICESHIP TRAINING
VA FILE NUMBER

TRAINEE'S NAME AND ADDRESS

PAYEE

IMPORTANT: Read the instructions carefully. You and the
employer should complete, date, and sign this form on or after the
last day of the last month shown in Item 1. Call 1-888-GI-BILL-1
(1-888-442-4551), if you have questions. If you use the
Telecommunications Device for the Deaf (TDD) call the Federal
Relay number is 711.

INSTRUCTIONS TO EMPLOYEE/CERTIFYING OFFICIAL
ITEMS 1 AND 2 - Enter the number of hours trained for each month/year shown (include any hours of related training given during working hours).
ITEM 3 - Check the appropriate box, and if training has been terminated, complete Items 4 and 5. If trainee has attained the complete job skills for their job (a
"journeyman" knowledge and skills), show this information in Item 5.
ITEMS 6A, 6B, AND 6C - Check the appropriate box. If trainee received a wage increase (or decrease) not in accordance with their training agreement, show the new
wage rate and the effective date of that wage rate (when trainee first received this wage rate).
ITEM 7 - Use Item 7, Remarks, to show any additional information concerning your wage rate. Also, if trainee are receiving additional educational allowance for
dependents use this item to report any change in the number of the trainee's dependents.
CHANGE OF ADDRESS - If the trainee is changing their address permanently, neatly line out the preprinted address shown above. Then, print or type your new address
in the remaining space. Be sure to include the ZIP Code.
Also use Item 7 if the trainee's conduct or progress is unsatisfactory or if the trainee has attained the complete job skills for the job (a "journeyman" knowledge and skills).
ITEMS 8A and 8B - Sign and date the form and return it to the VA office shown above.
If you have any questions, call VA toll-free at 1-888-GI Bill (1-888-442-4551).

1. MONTH(S)/YEAR TO BE CERTIFIED

2. NUMBER OF HOURS
WORKED
FOR EACH MONTH SHOWN IN
ITEM 1

3. WAS TRAINEE ENROLLED IN AND
PURSUING THE APPROVED PROGRAM
FOR THE MONTH(S) SHOWN IN ITEM 1?

4. DATE TERMINATED

(Month, day, year)

YES
NO

(If "No," complete Items 4 and 5)

5. REASON FOR TERMINATION

6A. IS WAGE RATE IN ACCORDANCE
WITH TRAINING AGREEMENT?
YES
NO

7. REMARKS

6B. RATE

6C. EFFECTIVE DATE

(If "No," complete Items 6B and 6C)

8A. SIGNATURE TRAINEE (Sign in ink)

8B. DATE SIGNED

9A. SIGNATURE AND TITLE OF CERTIFYING OFFICIAL (Sign in ink)

9B. DATE SIGNED

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) VA obtains 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 and Employment
Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits (licensing and certification test reimbursement). While you do not have to
respond, VA cannot reimburse you any licensing and certification test fees until we receive this information (38 U.S.C. 3452(b) and 3501(a)). Your responses are confidential (38 U.S.C.
5701). Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine your eligibility for reimbursement of licensing and certification test fees. We cannot pay you any education benefits for
this reimbursement until we receive this information (38 U.S.C. 5101). 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 1-888-GI-BILL-1
(1-800-442-4551) to get information on where to send comments or suggestions about this form. If you are hearing impaired, call 1-888-829-4833.
VA FORM
SUPERSEDES VA FORM 22-6553d-1, NOV 2018,
OCT 2019
WHICH WILL NOT BE USED.

22-6553d-1

FILE NUMBER:

I CERTIFY THAT the previous statements are true and correct to the best of my knowledge and belief.
PENALTY - Willful false reports concerning benefits payable by VA may result in fines or imprisonment or both.