VA Form 28-10286 Request for Retroactive Induction for a Period Previousl

OMB Approved No. 2900-XXXX
Respondent Burden: 20 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

REQUEST FOR RETROACTIVE INDUCTION FOR A PERIOD PREVIOUSLY
COMPLETED UNDER CHAPTER 33
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2.
Use this form to submit a request for retroactive induction for a period previously completed under
Chapter 33. Please refer to page 3 for information and instructions on how to complete this form and
submit additional required documentation for completion of this claim. For more information, you can
contact us online through Ask VA: https://ask.va.gov/. Ask us a question online or call us toll-free at
1-800-827-1000 (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, Evidence Intake Center, P.O. Box 4444,
Janesville, WI 53547-4444.

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, to help expedite processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)

2. VA FILE NUMBER (Last Four)

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

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

City
Country

ZIP Code/Postal Code

5. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number (If applicable)
6. E-MAIL ADDRESS

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

7. RETROACTIVE INDUCTION START DATE REQUESTED (MM/DD/YYYY) (NOTE: You will have 60 days from the date VR&E receives this claim to submit required
supporting documents. See Instructions on page 3 for additional information)

8. DID YOU RECEIVE A KICKER PAYMENT?
YES

NO

9. DID YOU RECEIVE THE EDITH NOURSE ROGERS SCIENCE TECHNOLOGY ENGINEERING MATH (STEM) SCHOLARSHIP PAYMENTS?
YES

NO

10. DO YOU REQUEST MOVEMENT OF ENTITLEMENT FOR APPROVED RETROACTIVE INDUCTION?
YES

NO

11. DO YOU REQUEST RETROACTIVE INDUCTION FOR THE DIFFERENCE IN WHAT YOU PAID FOR TUITION AND FEES?
YES

NO

12. DO YOU REQUEST RETROACTIVE INDUCTION FOR THE DIFFERENCE IN WHAT YOU PAID FOR BOOKS AND SUPPLIES?
YES

NO

13. DO YOU REQUEST RETROACTIVE INDUCTION FOR THE DIFFERENCE IN WHAT YOU RECEIVED AS A MONTHLY HOUSING ALLOWANCE?
YES

NO

SECTION II: VERIFICATION
14. I VERIFY THAT THE INFORMATION PROVIDED ABOVE IS ACCURATE AND INITIATES MY REQUEST FOR RETROACTIVE INDUCTION AS A RESULT OF MY
TRANSFER FROM CHAPTER 33 TO CHAPTER 31.
YES
VA FORM
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NO

28-10286

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SECTION II: VERIFICATION (Continued)
15. IF I RECEIVED KICKER PAYMENTS, I ACKNOWLEDGE THAT AN OVERPAYMENT FOR THE TOTAL AMOUNT OF KICKER PAYMENTS RECEIVED DURING
THE RETROACTIVE PERIOD WILL BE CREATED BY VA EDUCATION SERVICE AFTER ENTITLEMENT IS MOVED FROM CHAPTER 33 TO CHAPTER 31.
YES

NO

16. IF I RECEIVED STEM PAYMENTS, I ACKNOWLEDGE THAT AN OVERPAYMENT FOR THE TOTAL AMOUNT OF STEM PAYMENTS I RECEIVED DURING THE
RETOACTIVE PERIOD WILL BE CREATED AFTER ENTITLEMENT IS MOVED FROM CHAPTER 33 TO CHAPTER 31. YOU WILL BE SOLELY RESPONSIBLE FOR
THE DEBT IF THE ENROLLMENT PERIODS CANNOT BE INCLUDED IN THE RETROACTIVE INDUCTION. YOU MAY REAPPLY FOR STEM WHEN USING
CHAPTER 33 IN THE FUTURE, IF FUNDS ARE AVAILABLE.
YES

NO

17. DO YOU WISH TO WITHDRAW YOUR CLAIM FOR A RETROACTIVE INDUCTION FOR A PERIOD PREVIOUSLY COMPLETED UNDER CHAPTER 33?
NOTE: You may request to withdraw your claim until the retroactive induction is processed by the Regional Processing Office.
YES

NO

(If "Yes," sign and date in Items 18A and 18B)

SECTION III: CERTIFICATION AND SIGNATURE
I CERTIFY THAT I have completed this statement and that the information is true and correct to the best of my knowledge and belief.
18A. CLAIMANT AUTHORIZED SIGNATURE (Required)

18B. 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 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 Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to
respond is voluntary.
RESPONDENT BURDEN: This form is used to determine entitlement for a retroactive induction for a period previously completed with
Chapter 33 (38 U.S.C. 3102, 3103, 3108, 5113). Title 38, United States Code allows us to ask for this information. We estimate that you
will need an average of 20 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 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 28-10286, XXX XXXX

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INFORMATION AND INSTRUCTIONS
IMPORTANT: To qualify for a Retroactive Induction, you must first be found entitled to Chapter 31 benefits under 38 U.S.C. 3102. Furthermore,
you must meet all of the conditions for Retroactive Induction as outlined in 38 CFR 21.282(c).
HOW TO USE THIS FORM
Use this form to apply for a retroactive induction for a period previously completed under Chapter 33. You must be found entitled to Chapter 31 benefits
per 38 U.S.C. 3102, and meet all of the criteria listed in 38 CFR 21.282(c) to be approved for a retroactive induction. A retroactive induction may include
moving entitlement used in Chapter 33 to Chapter 31 for the approved retroactive period; and reimbursement for the difference in benefits, such as tuition,
fees, books, supplies and monthly allowance that you would have received during the retroactive period had you been using Chapter 31 instead of
Chapter 33. If you have reviewed the kicker and STEM information and have decided you no longer want to pursue a retroactive induction, you must
update this form (Item 17) to indicate you choose to withdraw your claim for retroactive induction for a period previously completed under Chapter 33.
You must submit all of the required documentation within 60 days of the date of submission of this claim to be evaluated for a retroactive induction.
Failure to do so will result in denial of the retroactive induction, or you may not receive all of the benefits you may have been entitled to.
Section I
If you checked "Yes," to question 10 on page 1, to request movement of entitlement for a period previously used under Chapter 33, if still within the
delimiting date, towards a Chapter 31 qualifying program, you must provide the following documentation:
• Dates of each term or period you would like to have considered for a possible retroactive induction,
• Transcript(s) that include the classes you completed during each requested retroactive term/period, and
• A degree audit that proves the classes you are requesting for consideration of a retroactive induction will apply to your identified vocational goal.
Note: Transfer of entitlement may not be a 1:1 transfer due the difference in how CH31 and CH33 count rate of pursuit. The following outlines the
differences between the two chapters:
• Chapter 33 charges rate of pursuit to the nearest 10 percent, starting at 60% and progressing to 70%, 80%, 90%, and 100% for full-time. In
determining this, Chapter 33 rounds to the nearest 10%.
• Chapter 31 charges rate of pursuit to the nearest ¼, starting at half-time (50%), three-quarter time (75%), and full-time (100%). In determining
this, Chapter 31 rounds down to the nearest ¼.
If you checked "Yes," to question 11 on page 1, to receive reimbursement for any difference in tuition and fees beyond what was paid under Chapter 33,
you must provide the following documentation:
• Dates of each term or period you would like reviewed for a possible retroactive induction, information from each facility you received training
from for the requested term/period. This information must indicate the total cost of tuition and fees, as well as how much and what type of funds
were applied to those costs (Pell Grant, Chapter 33, scholarships, student loans, etc.),
• Transcript(s) that includes the classes you completed during each requested retroactive term/period, and a degree audit that proves the classes
you are requesting for consideration of a retroactive induction will apply to your identified vocational goal.
Note: VR&E cannot reimburse you for what Chapter 33 paid, or any scholarships or grants that were applied to tuition and fees; however, tuition and fees
not covered by Chapter 33, which were paid out of pocket or paid by student loans can be considered for reimbursement.
If you checked "Yes," to question 12 on page 1, to receive reimbursement for any difference in the cost of books and supplies beyond the book stipend
you received from Chapter 33, you must provide the following documentation:
• Dates of each term or period you would like reviewed for a possible reimbursement,
• Completed VA Form (VAF) 28-1905m,
• Verification of books and supplies that were required for each course during the requested term/period (copy of a course syllabus or other
documentation from the instructor),
• Copies of receipts for books and supplies purchased for these courses.
Note: You must provide itemized receipts that show you paid more for the required books and supplies than the allowance you received under Chapter 33
to be reimbursed the difference.
If you checked "Yes," to question 13 on page 1, to request reimbursement for any difference in the monthly housing allowance, VR&E will review and
calculate this difference. To do this, you must provide the following documentation:
• Dates of each term or period you would like VR&E to review for a possible reimbursement.
Note: You can only qualify for the Post-9/11 Subsistence Allowance (P911SA) rate under Chapter 31 for terms that began on or after August 1, 2011.
Section II
In this section, verify you intend to initiate the claim for retroactive induction and that you are aware a debt will be created for STEM and kicker payments.
If you have reviewed the kicker and STEM information and have decided you no longer want to pursue the claim for retroactive induction, you must
update this form (Item 17) to indicate you choose to withdraw the request for retroactive induction for a period previously completed under Chapter 33.

VA FORM 28-10286, XXX XXXX

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