VA Form 22-0840 Accelerated Payment Verification of Completion Letter

In Reply Refer To:

Dear
The law requires that we collect some information about the accelerated payment of $
we sent you on (MM/DD/YYYY)
.
If you don't answer before (MM/DD/YYYY)
of $

, you must return the Accelerated Payment

You must sign and return this form to our office before (MM/DD/YYYY)
. You can mail it to
the address at the top of this letter. If you do not reply, you will be required to pay back $

Sincerely,
Education Officer

OMB Control No. 2900-0636
Respondent Burden: 5 Minutes
Expiration Date: XX/XX/XXXX

ACCELERATED PAYMENT VERIFICATION OF COMPLETION
Reminder: You must sign and return this form. If you do not, you will be required to pay back the full amount of your
accelerated payment.
1A. DID YOU INCREASE OR DECREASE THE
NUMBER OF CREDIT/HOURS PURSUED?
YES

NO (If "Yes," complete Items 1B thru 1D)

2A. DID YOU SUCCESSFULLY COMPLETE THE
COURSE(S)?
YES

1B. SPECIFY INCREASE OR DECREASE
INCREASE
DECREASE

1C. NUMBER OF HOURS

1D. DATE THE CHANGE IN HOURS OCCURRED (MM/DD/YYYY)
2B. DATE YOU LAST ATTENDED (MM/DD/YYYY)

NO (If "No," complete Items 2B thru 2C)

2C. EXPLAIN WHY YOU DIDN'T COMPLETE THE COURSE

VA FORM
XXX XXXX

22-0840

(Continued on Reverse)

3. HOW DID YOU USE YOUR PAYMENT? (Check the box that best describes how you used the majority of your payment. There is no right or

wrong answer. This information is being collected for statistical purposes only)

EDUCATION RELATED ITEMS (TUITION, FEES, BOOKS, SUPPLIES, ETC.)
PERSONAL ITEMS (ROOM, BOARD, LIVING EXPENSES, ETC.)
SAVINGS OR CHECKING ACCOUNT
TRAVEL OR ENTERTAINMENT
LOAN REPAYMENT
OTHER (Please specify)

4. REMARKS

I CERTIFY THAT the information given is true and correct to the best of my knowledge.
5A. SIGNATURE OF STUDENT (Sign in ink)

5B. DATE SIGNED (MM/DD/YYYY)

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 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. For example, a routine use that allows VA to
send educational forms or letters with an individual's identifying information to the individual's school or training establishment to (1) assist the
individual in the completion of claims forms or (2) for VA to obtain further information as may be necessary from the school for VA to properly
process the individual's education claim. Your obligation to respond is required to obtain or retain education benefits. If you do not respond, VA
must collect the payment made to you under 10 U.S.C 16131a, 16162a, or 38 U.S.C. 3014A. The responses you submit are considered
confidential (38 U.S.C. 5701). Any information provided by applicants, recipients, and others may be subject to verification through computer
matching programs with other agencies.

RESPONDENT BURDEN
We need this information to confirm your entitlement to the accelerated payment we issued to you (10 U.S.C. 16131a, 38 U.S.C. 3014A). Title
38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 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 1-888-GI-BILL-1 (1-888-442-4551) to get
information on where to send comments or suggestions about this form.
VA FORM 22-0840, XXX XXXX

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