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

OMB Approved No. 2900-0009
Respondent Burden: 10 minutes
Expiration Date: 08/31/2025

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 3.
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 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD),
the Federal relay number is 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 to
help expedite processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)

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

2. SOCIAL SECURITY NUMBER

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
Country

ZIP Code/Postal Code

6. MAIN TELEPHONE NUMBER (Include Area Code, or check "None" if no available telephone number)
None

Enter International Phone Number (If applicable)

7. CELL PHONE NUMBER (Include Area Code, or check "None" if no available cell phone number)
None
8. E-MAIL ADDRESS OF CLAIMANT

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

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: PROTECTION OF PRIVACY INFORMATION STATEMENT
(For Use By Counselees and Rehabilitation Program Participants)
I HAVE BEEN INFORMED AND UNDERSTAND that the information requested in this and any later interviews is requested under the authorization of Title 38,
United States Code of Federal Regulations 1.576, Veterans Benefits. This information is needed to assist in vocational and educational planning, to authorize my receipt
of rehabilitation services, to develop a record of my vocational progress, and to assure I obtain the best results from my rehabilitation program. I understand that the
information I provide will not be used for any other purpose and that my responses may be disclosed outside VA only if the disclosure is authorized under the Privacy Act
of 1974, including the routine uses 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. Generally, disclosures under the authority of a routine use will be made to develop my claim for vocational rehabilitation
benefits under Title 38, United States Code.
VA FORM
APR 2024

28-1900

SUPERSEDES VA FORM 28-1900, AUG 2022,
WHICH WILL NOT BE USED.

Page 1

SECTION II: PROTECTION OF PRIVACY INFORMATION STATEMENT (Continued)
(For Use By Counselees and Rehabilitation Program Participants)
My giving the requested information is voluntary. I understand that the following results might occur if I do not give this information:
(1) I may not receive the maximum benefit either from counseling or from my education or rehabilitation program.
(2) If certain information is required before I may enter a VA program, my failure to give the information my result in my not receiving the education or rehabilitation
benefit for which I have applied.
(3) If I am in a program in which information on my progress is required, my failure to give this information may result in my not receiving further benefits or services.
My failure to give this information will not have a negative effect on any other benefit to which I may be entitled.
I acknowledge I have read the Protection of Privacy Information Statement.

SECTION III: 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 28-1900, APR 2024

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

Page 2

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: 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 2900-0009, and it expires August 31, 2025. 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. 2900-0009 in any correspondence. Do not send your completed VA Form 28-1900 to this email address.

VA FORM 28-1900, APR 2024

Page 3