Form VA Form 28-1900 VA Form 28-1900 Application for Veteran Readiness and Employment for Cla

OMB Approved No. 2900-0009
Respondent Burden: 10 minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR VETERAN READINESS AND EMPLOYMENT FOR CLAIMANTS
WITH SERVICE-CONNECTED DISABILITIES
(Chapter 31, Title 38, U.S.C.)
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden information on
page 2. Use this form to apply for Veteran Readiness and Employment Services. For more information contact
us online at www.va.gov/contact-us or call toll-free at 800-827-1000 (TTY:711). VA forms are available at:
www.va.gov/vaforms. After completing the form if returning by mail, mail to: Department of Veterans Affairs,
Veteran Readiness and Employment (VR&E) Intake Center, P.O. Box 5210, Janesville, WI 53547-5210.

SECTION I: CLAIMANT'S INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly, insert one letter per
box and completely fill in each applicable circle to help expedite processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If different from Item 2)

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

5. MAILING ADDRESS (Number and street or rural route, City, State and ZIP Code, OR write "None," if no mailing address)
No. &
Street
Apt./Unit Number
State/Province

City
ZIP Code/Postal Code

Country

6. MAIN TELEPHONE NUMBER (Include Area Code, or write "None" if no available telephone number)
Enter International Phone Number (If applicable)
7. CELL PHONE NUMBER (Include Area Code, or write "None" if no available cell phone number)

8. E-MAIL ADDRESS OF CLAIMANT

9. IF YOU ARE MOVING WITHIN THE NEXT 30 DAYS, PROVIDE YOUR NEW ADDRESS BELOW
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

10. NUMBER OF YEARS OF EDUCATION

SECTION II: CERTIFICATION AND SIGNATURE

I HEREBY CERTIFY THAT the information I have entered on this form is true and complete to the best of my knowledge and belief.
I realize that making willful false statements concerning a material fact in a claim for chapter 31 benefits is a punishable offense that
may result in a fine or imprisonment, or both. (Reference: 38 U.S.C. 3802(a))
11A. SIGNATURE OF CLAIMANT

VA FORM
XXX XXXX

28-1900

11B. DATE SIGNED (MM-DD-YYYY)

SUPERSEDES VA FORM 28-1900, NOV 2019,
WHICH WILL NOT BE USED.

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INSTRUCTIONS FOR APPLYING FOR VETERAN READINESS AND EMPLOYMENT
TO APPLY OR RECEIVE INFORMATION AND ASSISTANCE:
• To apply, you may submit the completed application to Department of Veterans Affairs, Veteran Readiness and Employment (VR&E)
Intake Center, P. O. Box 5210, Janesville, WI 53547-5210 or apply online at www.va.gov.
• You may obtain information and assistance from any Veterans Benefits Administration (VBA) office or online at www.va.gov.
• A representative of a Veterans Service organization and the American Red Cross also have information and forms available.
• Mailing Address: You will not be denied benefits on the basis that you do not have a mailing address under the provisions of 38 U.S.C.
5126. If you do not have a mailing address, please write “none” in response to question 5. However, you must provide an alternative
means of contact if you are unable to provide an address or telephone number, so we can schedule your initial evaluation appointment.
EVALUATION: A combined and compensable service-connected disability rating of 10 percent or more by VA is required for you to apply
for vocational rehabilitation services. Once your application is received, we will provide you with a comprehensive evaluation where a VA
Vocational Rehabilitation Counselor (VRC) will work with you to determine:
1. If you meet the requirements for entitlement Chapter 31 benefits.
2. If you are within the time limit for receiving this benefit, which is generally 12 years from the date VA notified you of your
compensation rating for at least a 10% service-connected disability. This 12-year period does not apply if you were discharged
on or after January 1, 2013.
PLANNING AND COUNSELING: After a VRC determines that you meet the entitlement requirements, your assigned VRC will assess
your vocational rehabilitation and employment needs with you. Subsequently, your VRC will develop a plan of services and assistance
with you to help you reach your employment goal. Counseling will be available throughout your program to help you when problems arise.
REHABILITATION SERVICES: Vocational rehabilitation programs do not always require training. You may only need employment
services to help you get a suitable job. If your VRC determines that you need training to reach your vocational goal, he or she will also
determine the number of months needed to complete your training. You may train in a vocational school, a specialized rehabilitation
facility, an apprenticeship program, other on-job training position, a college, or a university. VA will provide medical and dental care
treatment, assistance to get and keep suitable employment, and other services you may need. If employment is not currently feasible for
you, VA may provide services and assistance to improve your ability to live independently.
SUPPORT: VA may pay for tuition, fees, books, equipment, tools, or other supplies you need to succeed in your rehabilitation program.
During your training, you may qualify for a monthly subsistence allowance to help you with your living expenses. Payment for subsistence
allowance depends on a variety of factors, which may include your type of training, rate of attendance, and number of dependents. You
will receive this allowance in addition to any VA compensation or military retired pay that you may be receiving.

PRIVACY ACT INFORMATION: The responses you submit are considered confidential (38 U.S.C. 5701). Your obligation to respond is required in order to
obtain benefits. 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 Veteran Readiness and Employment Records - VA, published in the Federal Register. Your
response is required to obtain benefits (5 CFR 1320.8(b)(3)(iv)). Giving us your Social Security Number (SSN) information is mandatory. Applicants are
required to provide their SSN under Title 38 USC 5101 (c) (1). The VA will not deny benefits for any individual refusing to provide his or her SSN unless the
disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. 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 benefit program administered by the Department of Veterans
Affairs.
RESPONDENT BURDEN: This form is used to determine entitlement to Chapter 31 benefits (38 U.S.C. 3102). 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. Valid OMB number 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 28-1900, XXX XXXX

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