Form VA Form 21-8960-1 VA Form 21-8960-1 Certification of School Attendance or Termination

File Number:

Name of Student:

Birth Date of Student:

Because we are paying Department of Veterans Affairs benefits based on your report that the student named above is attending school,
we ask that you verify the student's school attendance for this school year. Please answer the questions below, sign and date the form,
and return it within 60 days to the VA office address shown above. Otherwise, benefits based upon the student's attendance will be
discontinued.
OMB Control No. 2900-0458
Respondent Burden: 10 minutes
Expiration Date: XX/XX/XXXX

CERTIFICATION OF SCHOOL ATTENDANCE OR TERMINATION
SECTION I: VETERAN'S INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly, and legibly to help process
the form.
1. VETERAN/BENEFICIARY NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

5. VETERAN'S SERVICE NUMBER (If applicable)

6. TELEPHONE NUMBER (Include Area Code)

4. DATE OF BIRTH (MM/DD/YYYY)

7. E-MAIL ADDRESS (Optional)

8. PREFERRED MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
Country

State/Province

ZIP Code/Postal Code

SECTION II: STUDENT'S INFORMATION
9. IS THE STUDENT NOW IN SCHOOL?
YES

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NO

(If "No," do NOT complete Items 10 and 12.
Give the date and reason school attendance terminated)

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EXISTING STOCK OF VA FORM 21-8960-1, OCT 2014, WILL BE USED.

VETERAN'S SOCIAL SECURITY NO.
10. HAS THE STUDENT ATTENDED SCHOOL FROM THE OFFICIAL BEGINNING OF THE SCHOOL YEAR? 11. IS THE STUDENT MARRIED? (If, "YES," give the date)
YES

NO

(If "No," enter the inclusive dates of
the student's school attendance)

YES

NO

DATE OF MARRIAGE (MM/DD/YYYY)

12. NAME OF LAST SCHOOL ATTENDED

13. HAS THE STUDENT ATTENDED ANY OTHER SCHOOL
(S) THIS YEAR? (If "YES", list the school(s) attended in the
space provided)
YES

14. WHEN DOES THE STUDENT EXPECT TO
GRADUATE OR OTHERWISE TERMINATE THE
COURSE OF STUDY? (Give date)

NO
DATE OF GRADUATION (MM/DD/YYYY)

15. HAS THE STUDENT BEGUN RECEIVING OR APPLIED FOR VA DEPENDENTS' EDUCATIONAL ASSISTANCE (DEA), FEDERAL EMPLOYEES' COMPENSATION
ACT PAYMENTS, OR BENEFITS FROM ANY OTHER FEDERAL AGENCY SUCH AS THE U.S. SERVICE ACADEMY, U.S. MERCHANT MARINE ACADEMY,
BUREAU OF INDIAN AFFAIRS, ETC., THAT IS OR WILL BEGIN TO PAY THE STUDENT'S TUITION?
YES

NO

(NOTE: Concurrent receipt of DEA benefits by the student and additional compensation payments based on that student's school
attendance is considered a duplication of benefits and is prohibited by law.)

NOTE: The student should sign this form only if the student is receiving benefits in his or her own right. Otherwise, the parent, guardian, or custodian should sign
in Item 16 and enter his or her relationship to the student in Item 17.
I AGREE to notify the Department of Veterans Affairs immediately of any changes in this course of education, transfer to another school, discontinuance of school
attendance or marriage prior to completion of the course. I understand that continued entitlement to school attendance benefits may be based on the information I have
furnished on this form. Any benefits allowed due to this certification will be discontinued if the student marries or leaves school, or upon the death of the student.
I CERTIFY THAT the information provided is true and correct to the best of my knowledge and belief.
16. SIGNATURE

17. RELATIONSHIP TO STUDENT

18. 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, or
fraudulent acceptance of any payment to which you are not entitled.

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 38, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional
communications, epidemiological ore 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, and Vocational Rehabilitation and
Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested
information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered 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 continued eligibility to benefits for a veteran's child who is over age 18 and
attending school (38 U.S.C.). 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 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.
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EXISTING STOCK OF VA FORM 21-8960-1, OCT 2014, WILL BE USED.