Form VA Form 22-1990t VA Form 22-1990t Application for Individualized Tutorial Assistance

OMB Approved No. 2900-0171
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX

APPLICATION FOR INDIVIDUALIZED TUTORIAL ASSISTANCE
1. NAME OF
APPLICANT
2. NAME OF
VETERAN
(If other than
applicant)

FIRST NAME

M.I.

LAST NAME

FIRST NAME

M.I.

LAST NAME

3. MAILING ADDRESS

4A. VA FILE NUMBER

NUMBER AND STREET OR RURAL ROUTE

4B. PAYEE

OR
SOCIAL SECURITY NUMBER

APARTMENT OR BOX NUMBER

STATE

6. DATE OF BIRTH

5. SEX

CITY OR POST OFFICE

FEMALE
MALE

ZIP CODE OR FOREIGN MAIL CODE

7. NAME OF YOUR COURSE OR CURRICULUM

8. CREDIT OR CLOCK HOUR LOAD

10. UNIT SUBJECT OR SUBJECTS IN WHICH YOU REQUIRE INDIVIDUALIZED
TUTORING

MONTH

DAY

YEAR

9. FINAL EDUCATIONAL, PROFESSIONAL, OR
VOCATIONAL GOAL
11. NAME, POSITION AND ADDRESS OF TUTOR

12. SCHEDULE AND CHARGES FOR TUTORIAL ASSISTANCE
A. MONTH AND
YEAR

B. EXACT DATES
OF SESSIONS

C. NUMBER OF HOURS
OF INSTRUCTION THIS MONTH

D. CHARGE PER
HOUR

E. TOTAL CHARGES
THIS MONTH

F. TOTAL PAYMENT DUE
13B. DATE SIGNED

13A. SIGNATURE OF APPLICANT (Do NOT print)

13C. E-MAIL ADDRESS OF APPLICANT (If applicable)

I CERTIFY THAT: (1) I gave the applicant individualized tutorial assistance as shown above; (2) the charges to the applicant shown
above are correct; and (3) I am not a close relative (i.e., spouse, parent, child, brother, sister) of the applicant.
14B. DATE SIGNED

14A. SIGNATURE OF TUTOR (Do NOT print)

I CERTIFY THAT: (1) The individualized tutorial assistance for the unit subject or subjects shown was required for the satisfactory
pursuit of the student's approved program; (2) the tutor is qualified to conduct individualized tutorial assistance; and (3) the charges do
not exceed the customary charges for other students who receive the same tutorial assistance.
15. NAME AND ADDRESS OF EDUCATIONAL INSTITUTION

16. INDICATE TYPE OF SCHOOL
FOUR-YEAR
COLLEGE

17A. SIGNATURE AND TITLE OF CERTIFYING OFFICIAL

TWO-YEAR
COLLEGE

OTHER THAN
COLLEGE

17B. DATE SIGNED

Additional Certification required to receive tutorial assistance under the Post-9/11 GI Bill (chapter 33)

I CERTIFY THAT: (1) Tutorial assistance benefits are essential to correct a deficiency of this student in the course and; (2) that the
course is required as part of, or is prerequisite or indispensable to the satisfactory pursuit of, an approved program of education.
18A. SIGNATURE OF PROFESSOR OR INSTRUCTOR

18B. DATE SIGNED

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.
APPROVAL DATE

VA FORM
XXX XXXX

SIGNATURE OF ADJUDICATOR

22-1990t

FOR VA USE ONLY

SIGNATURE OF FINANCE OFFICER (or designee)

SUPERSEDES VA FORM 22-1990t, OCT 2018,
WHICH WILL NOT BE USED.

DATE

STATION
NUMBER
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INFORMATION AND INSTRUCTIONS
GENERAL INFORMATION: To apply for tutorial assistance read these instructions and complete the form in full. If you need help,
reach us on the Internet at www.benefits.va.gov/gibill/. You can call VA toll-free at 1-888-GIBILL1 (1-888-442-4551). If you
use the Telecommunications Device for the Deaf (TDD), the Federal Relay number is 711. To obtain information on other forms of
assistance, contact the financial aid office at your school.
ELIGIBILITY: If you are eligible for education benefits and need help in a subject, you can get supplemental payments for tutorial
assistance. The subject must be necessary for the completion of your approved program. You must be training at one-half time or
more in a post-secondary program at an educational institution. Even if you are passing a course, you can get tutorial assistance if
your grade will not be credited toward completion of your program.

CLAIMS FOR TUTORIAL ASSISTANCE: After you have received tutoring, do the following:
Step 1. Fill out the form.
• Complete Items 1 through 13.
• In Item 10, show the individual unit subject or subjects (e.g., Math 101) for which you needed tutoring.
• Be sure to complete all blocks A through F in Item 12. If any block is not checked, your payment may be delayed.
Step 2. Take to your tutor. The tutor must:
• Sign and date the application in Items 14A and 14B.
• Verify the information you provided.
• Certify that he or she is the person who gave you individualized tutoring, and is not closely related to you (i.e., spouse, parent,
brother, sister or child).
Step 3. Take to the certifying official for VA Benefits at the school. The certifying official must:
• Complete Items 15 and 16.
• Sign in Items 17A and 17B.
Step 4. Post-9/11 GI Bill. If you are requesting tutorial assistance under the Post-9/11 GI Bill, take this form to the professor or
instructor of the course for which tutoring was necessary. The teacher must:
• Sign Item 18A.
• Complete Item 18B.
Step 5. Review the form. After you have completed the form (see steps 1 through 4), send it to VA as soon as possible after your
tutoring is complete. VA will not pay assistance for any tutoring received more than one year before the day VA actually receives
your claim.
Step 6. Where to Mail This Form. Mail the completed form to the Regional Processing Office for your state. See the chart on
page 3.

PAYMENTS: VA will pay up to $100 per month for your tutorial assistance. The tutorial assistance you get will be in addition to
your regular monthly education benefits for going to school.
ENTITLEMENT: The limit for tutorial assistance is $1,200 (12 times the maximum monthly rate of $100).

Special provisions:
1. If you are training under 38 U.S.C. Chapter 30 or 32, or under 10 U.S.C. Chapter 1606, or Section 903 of Public Law 96-342,
VA will not charge entitlement for your first $600 of tutorial assistance. For tutorial assistance over $600, VA will charge one
month of entitlement whenever you receive an amount equal to the full-time monthly rate you get for going to school.
2. If you are training under 38 U.S.C. Chapter 33 or 35, or the Omnibus Diplomatic Security and Antiterrorism Act of 1986, VA
will not charge you any entitlement for tutorial assistance.
VA FORM 22-1990t, XXX XXXX

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Eastern Region:
VA Regional Office
P. O. Box 4616
Buffalo, NY 14240-4616
SERVES THE FOLLOWING STATES

CO

CT

DC

DE

IA

IL

IN

KS

KY

MA

MD

ME

MI

MN

MO

MT

NC

ND

NE

NH

NJ

NY

OH

PA

RI

SD

TN

VA

VT

WI

WV

WY

US Virgin
Islands

Foreign
Schools

APO/FPO AA

Western Region:
VA Regional Office
P. O. Box 8888
Muskogee, OK 74402-8888
SERVES THE FOLLOWING STATES

AK

AL

AR

AZ

CA

FL

GA

HI

ID

LA

MS

NM

NV

OK

OR

PR

SC

TX

UT

WA

APO/FPO AP

Guam

Philippines

PRIVACY ACT NOTICE: VA will not disclose information collected by this information collection to any source other than what has been
authorized by 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,
58VA21/22/28, 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 education claims form 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. 3019, 3234, 3492, and 3533 and 10 U.S.C. (16131). Your responses are confidential (38 U.S.C. 5701. Any information provided by applicants,
and others may be subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine your eligibility to receive VA tutorial assistance, and the amount paid. Title 38,
United States Code allows us to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions, find the
information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid OMB (Office of Management and
Budget) 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, call 1-888-442-4551 to get information
on where to send your comments or suggestions about this form.

VA FORM 22-1990t, XXX XXXX

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