VA Form 21-8960 Certification of School Attendance or Termination

File Number:

Name of Student:

Birth Date of Student (MM/DD/YYYY):

Since, we are paying you Department of Veteran Affairs benefits based on your report that the student named above is attending school,
we ask that you verify the student's school attendance for this school year. Please complete the questions below, sign and date, and
return within 60 days to: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547-4444.
Otherwise, benefits based upon the student's attendance will be discontinued.
OMB Control No. 2900-0458
Respondent Burden: 10 minutes
Expiration Date: XX/XX/20XX

CERTIFICATION OF SCHOOL ATTENDANCE OR TERMINATION
SECTION I: VETERAN'S INFORMATION

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested, neatly and legibly, insert one letter per box, and
completely fill in each applicable check box to help expedite processing of the form.
1. VETERAN/BENEFICIARY NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

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

3. VA FILE NUMBER

5. VETERAN'S SERVICE NUMBER (If applicable)

6. TELEPHONE NUMBER (Include Area Code)

7. E-MAIL ADDRESS (Optional)

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

City
Country

ZIP Code/Postal Code

SECTION II: STUDENT'S INFORMATION
9. IS THE STUDENT NOW IN SCHOOL?
YES

VA FORM
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NO (If "No," do NOT complete Items 10 and 12. Give the date (MM/DD/YYYY) and reason school attendance terminated)

21-8960

SUPERSEDES VA FORM 21-8960, JUL 2021.

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VETERAN'S SOCIAL SECURITY NO.
10. HAS THE STUDENT ATTENDED SCHOOL FROM THE OFFICIAL BEGINNING OF THE SCHOOL YEAR?
YES
NO (If "No," enter all the dates (MM/DD/YYYY) of the student's school attendance)

11. IS THE STUDENT MARRIED?

DATE OF MARRIAGE (MM/DD/YYYY)

12. NAME OF LAST SCHOOL ATTENDED

YES (If, "YES," give the date)
NO
13. HAS THE STUDENT ATTENDED ANY OTHER SCHOOL(S) THIS YEAR?
YES (If, "YES," list the names of any other schools attended)
NO

14. WHEN DOES THE STUDENT EXPECT TO GRADUATE OR
OTHERWISE TERMINATE THE COURSE OF STUDY? (Give

date) (MM/DD/YYYY)

15. HAS THE STUDENT BEGUN RECEIVING OR APPLIED FOR VA DEPENDENTS' EDUCATIONAL ASSISTANCE (DEA), FEDERAL EMPLOYEES' COMPENSATION
ACT PAYMENTS, OR BENEFITS FROM ANY OTHER FEDERAL AGENCY SUCH AS THE U.S. SERVICE ACADEMY, U.S. MERCHANT MARINE ACADEMY,
BUREAU OF INDIAN AFFAIRS, ETC., THAT IS OR WILL BEGIN TO PAY THE STUDENT'S TUITION?
YES
NO

(NOTE: Concurrent receipt of DEA benefits by the student and additional compensation payments based on that student's school attendance is considered
a duplication of benefits and is prohibited by law.)

NOTE: The student should sign this form only if the student is receiving benefits in his or her own right. Otherwise, the parent, guardian, or custodian should sign in
Item 16 and enter his or her relationship to the student in Item 17.
I AGREE to notify the Department of Veterans Affairs immediately of any changes in this course of education, transfer to another school, discontinuance of school
attendance or marriage prior to completion of the course. I understand that continued entitlement to school attendance benefits may be based on the information I have
furnished on this form. Any benefits allowed due to this certification will be discontinued if the student marries or leaves school, or upon the death of the student.
I CERTIFY THAT the information provided is true and correct to the best of my knowledge and belief.
16. VETERAN/CLAIMANT/STUDENT'S SIGNATURE (REQUIRED)

17. RELATIONSHIP TO STUDENT

18. DATE SIGNED (MM/DD/YYYY)

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material
fact, knowing it to be false, or fraudulent acceptance of any payment to which you are not entitled.
PRIVACY ACT INFORMATION: The 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 ore 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 required to obtain or retain benefits. The requested information is considered relevant and necessary to determine maximum
benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is 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 2900-0458, 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. 2900-0458 in any correspondence. Do not send your completed VA Form 21-8960 to this
email address.

VA FORM 21-8960, XXX XXXX

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