Form VA Form 28-10212 VA Form 28-10212 Chapter 31 Request for Assistance

OMB Control No. 2900-0882
Respondent Burden: 10 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

CHAPTER 31 REQUEST FOR ASSISTANCE
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent
Burden on page 2. Use this form to submit a request for assistance with your Chapter 31
benefits. For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free
at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the
Federal relay number is 711. VA Forms are available at www.va.gov/vaforms.
SECTION I: CLAIMANT'S INFORMATION
NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite
processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)

2. VA FILE NUMBER

3. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

Country

State/Province

ZIP Code/Postal Code

4. TELEPHONE NUMBER(S) (Include Area Code)
Daytime:
Cell phone:

International Telephone Number (If applicable):
5. E-MAIL ADDRESS (Optional)

I agree to receive electronic correspondence from VA in regards to my claim.

SECTION II: ASSISTANCE YOU ARE REQUESTING
(IMPORTANT: Sections II and III must be completed in order to process your request)
6. SELECT THE ASSISTANCE YOU ARE REQUESTING, BELOW:
WITHDRAW MY APPLICATION FOR CHAPTER 31 BENEFITS
REQUEST FOR A REVOLVING FUND LOAN
REQUEST FOR REIMBURSEMENT
MITIGATING CIRCUMSTANCES FOR REDUCTION OR COMPLETE
WITHDRAWAL FROM TRAINING

REQUEST TO DISCONTINUE MY CHAPTER 31 PROGRAM AND CLOSE
MY CASE
REQUEST FOR SUPPLIES OR EQUIPMENT TO PARTICIPATE IN MY
REHABILITATION PROGRAM
DISCUSS AN ISSUE/CONCERN REGARDING MY REHABILITATION
SERVICES

OTHER (Specify)

VA FORM
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28-10212

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SECTION III: ADDITIONAL INFORMATION NEEDED TO PROCESS REQUEST
(Use this section to describe and explain the reason for the requested assistance)
7. REMARKS

SECTION IV: CERTIFICATION AND SIGNATURE
I CERTIFY THAT I have filled this form out completely and that it is true and correct to the best of my knowledge and belief.
8A.SIGNATURE OF CLAIMANT (REQUIRED)

8B. DATE SIGNED (MM-DD-YYYY)

PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be
false, or for fraudulent receipt of any document you are not entitled to.

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 (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is voluntary.
RESPONDENT BURDEN: This form is used to submit a request for assistance by a Chapter 31 claimant. 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 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 28-10212, XXX XXXX

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