22-1919 Conflicting Interests Certification for Proprietary Scho

OMB Control No. 2900-0657
Respondent Burden: 10 Minutes
Expiration Date: XXXXXXXXX

CONFLICTING INTERESTS CERTIFICATION FOR
PROPRIETARY SCHOOLS
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, Veteran
Readiness and Employment Records - VA, published in the Federal Register. An example of a routine use allows VA to send educational forms or letters with a
veteran's identifying information to the veteran's school or training establishment to (1) assist the veteran 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 veteran's education claim or to monitor his or her progress during training. Your
response is required to obtain or retain benefits. We cannot pay education benefits to any person training at your school until we receive this information (38 U.S.C.
3686(b)). Your responses are 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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 2900-0657, and it expires XX/XX/20XX. Public reporting burden for this collection
of information is estimated to average 10 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of
this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to
OMB Control No. 2900-0657 in any correspondence. Do not send your completed VA Form 22-1919 to this email address.
NAME AND ADDRESS OF INSTITUTION

PURPOSE: This form informs individuals that the law has restrictions concerning any potential conflict of interest. (See certifications (1) and (2)
below).
(1) PROPRIETARY PROFIT SCHOOLS ONLY
Title 38 U.S.C. 3683 prohibits employees of the Department of Veterans Affairs (VA) and the State Approving Agency (SAA) from owning any
interest in an educational institution operated for profit. The law prohibits these employees from receiving any wages, salary, dividends, profits or
gifts from for-profit schools. In addition, the law prohibits VA employees from receiving any services from these schools. These provisions may be
waived if VA determines that no detriment will result to the government, or to veterans or eligible persons. Please list below those VA and SAA
employees known by you who may have a potential conflict of interest under this provision. If there are none, please enter the word "none."
NAME AND TITLE OF EMPLOYEES(S)

DESCRIPTION OF ASSOCIATION WITH SCHOOL

(2) ALL PROPRIETARY SCHOOLS (Excludes Public Schools)
Title 38 C.F.R. 21.4202(c), 21.5200(c), 21.7122(e)(6), and 21.7622(f)(4)(iv) prohibit the payment of educational assistance to any veteran or eligible
person based on an enrollment in any proprietary school of which the veteran or eligible person is an official authorized to sign certificates of
enrollment or verifications/certifications of attendance, or is an owner or an officer. Please list below the names and VA file numbers (claim or Social
Security Numbers) of any certifying officials, owners, or officers of your school who receive VA educational assistance based on an enrollment in
your school. If there are none, please enter the word "none."
NAME AND TITLE OF EMPLOYEE(S)

VA FILE NUMBER

DATES OF ENROLLMENT WITH YOUR SCHOOL

(MM/DD/YYYY)

FROM

TO

CERTIFICATION: I DO HEREBY CERTIFY that the entries above are true and correct to the best of my knowledge. I agree to immediately
notify VA of any potential violations of the above prohibitions.
NAME AND SIGNATURE OF PRESIDENT OR CHIEF ADMINISTRATIVE
OFFICIAL OF SCHOOL

VA FORM
XXX XXXX

22-1919

TITLE

SUPERSEDES VA FORM 22-1919, MAR 2021,
WHICH WILL NOT BE USED.

DATE SIGNED

(MM/DD/YYYY)