Form FL 21-863 FL 21-863 Request for Information to Make Direct Payment to Child

DEPARTMENT OF VETERANS AFFAIRS

.

In Reply Refer To:

based on

You have been receiving VA benefits for
school attendance beyond age 18.
Our records show that this student will reach age of majority in
and, thereafter, will be entitled to receive direct payment.

VA payments may be continued up to the student's 23rd birthday, but will be terminated before then if the
student marries, completes the course of study, or withdraws from school.
To avoid any delay in future checks, the student must furnish the information requested below. Answer
Items 1A through 7, and return this letter to this office as soon as possible. If you have any questions, call
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number
is 711.
Sincerely yours,
OMB Control No. 2900-0215
Respondent Burden: 10 Minutes
Expiration Date: XXXXXX
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., 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, and Vocational Rehabilitation and Employment Records - VA, and published in the Federal Register. Your obligation to respond
is required to obtain or retain benefits. Information that you furnish may be utilized in computer matching programs with other Federal or
State agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United
States by virtue of your participation in any benefits program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: We need this information to determine continued eligibility for death benefits and entitlement to direct payment
(38 U.S.C. 1313 and 1542). 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. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.
TELEPHONE NUMBER(S) (Include Area Code)
1A. STUDENT'S ADDRESS (For check mailing purposes)
1B. DAYTIME
2A. IS STUDENT ATTENDING SCHOOL?

1C. NIGHTTIME

2B. NAME AND ADDRESS OF SCHOOL

YES (If "Yes," complete Items 2B and 2C)
NO (If "No," complete Items 3 and 4)
2C. DATE OF GRADUATION

(MM/DD/YYYY) (Anticipated date of
graduation or completion of course
of study)

3. DATE SCHOOL ATTENDANCE TERMINATED (MM/DD/YYYY)

5A. IS STUDENT MARRIED?
YES

5B. DATE OF MARRIAGE (MM/DD/YYYY) 5C. PLACE OF MARRIAGE (City, State or Country)

NO

6. SIGNATURE (Sign in ink)
FL 21P-863
XXXX

4. REASON FOR TERMINATION OF ATTENDANCE

7. DATE (MM/DD/YYYY)