21P-8938-1 Student Beneficiary Report - REPS (Restored Entitlement

OMB Approved No. 2900-0399
Respondent Burden: 20 Minutes
Expiration Date: XX/XX/20XX

STUDENT BENEFICIARY REPORT - REPS
(RESTORED ENTITLEMENT PROGRAM FOR SURVIVORS)
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 5, Code of
Federal Regulations 1.526 for routine uses (i.e., (Routine Uses 1 through 63) 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. Giving us your SSN account information is voluntary. No benefits may
be granted unless this form is completed fully as required by law (38 U.S.C. 5101). Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual
benefits for 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.
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 2900-0399, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 20 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. 2900-0399 in any correspondence. Do not send your completed VA Form 21P-8938-1 to this email address
.

SECTION I - STUDENT IDENTIFICATION
1A. NAME AND ADDRESS OF STUDENT (First, middle, last name)

1B. VETERAN/WAGE EARNER'S
SOCIAL SECURITY NO.

1C. STUDENT'S SOCIAL SECURITY NO.

2. PERIOD OF ATTENDANCE
A. BEGINNING DATE (MM/DD/YYYY)

B. ENDING DATE (MM/DD/YYYY)

(If different from above, furnish current address)
INSTRUCTIONS: STUDENTS - You must complete Section II, Student Certification, and have a school official verify your attendance. SCHOOL OFFICIALS - Please
complete Section III, School Official Certification, and return it promptly as failure to do so will result in suspension of the student's benefit payment. This form should be
returned to the VA REGIONAL OFFICE (331/21Q), 400 SOUTH 18TH STREET, ST. LOUIS, MO 63103-2271. (NOTE: DO NOT USE "NA" OR "UNKNOWN" IN ITEMS
REQUIRING COMPLETION.) IMPORTANT - THIS FORM SHOULD NOT BE RETURNED TO THE STUDENT.
SECTION II - STUDENT CERTIFICATION
3. NAME OF SCHOOL YOU ATTENDED
DURING PERIOD(S) SHOWN IN ITEM
2

4A. HAVE YOU ATTENDED SCHOOL
ON A FULL-TIME BASIS FOR PERIOD
SHOWN IN ITEM 2?

YES

UNDERGRAD

NO (If "NO," complete Item 5)

OTHER

NO (If "NO," complete Item 7)

8A. WILL YOU ATTEND THE SCHOOL
SHOWN IN ITEM 3?

GRAD

YES

6. WILL YOU CONTINUE SCHOOL ON A FULL-TIME BASIS AFTER THE END OF
THE PERIOD SHOWN IN ITEM 2?

8B. NAME AND ADDRESS OF NEW
SCHOOL

5. LIST DATES OF FULL-TIME
ATTENDANCE IF DIFFERENT FROM
ITEM 2

4B. TYPE OF DEGREE

7. DATES OF YOUR NEXT SCHOOL YEAR
A. BEGINNING DATE (MM/DD/YYYY)

B. ENDING DATE (MM/DD/YYYY)
8D. TYPE OF DEGREE

8C. TYPE OF NEW SCHOOL
COLLEGE OR UNIVERSITY

GRAD

YES

TECHNICAL, TRADE, OR VOCATIONAL

UNDERGRAD

NO (If "NO," complete Item 8B thru 8D)

OTHER (Specify):

OTHER

9. EARNINGS/WAGES RECEIVED FOR PRIOR YEAR

(Enter dollar amount or "None")

YEAR

AMOUNT

11. HAVE YOU OR WILL YOU BE PAID BY YOUR
EMPLOYER FOR ATTENDING SCHOOL?
YES

10. EARNINGS EXPETED THIS YEAR
YEAR

(Enter dollar amount or "None")

AMOUNT

YEAR

AMOUNT

12B. DATE(S) OF MARRIAGE (MM/DD/YYYY)

12A. HAVE YOU EVER BEEN MARRIED?
YES (If "YES," complete Item 12B)

NO

11. EARNINGS EXPECTED NEXT YEAR

(Enter dollar amount or "None")

NO

IMPORTANT: IT IS YOUR DUTY TO REPORT ANY CHANGE IN STATUS. You must notify the VA immediately of any change in school enrollment, marital or work
status, as benefits may be affected.
I CERTIFY THAT the previous statements are true and correct to the best of my knowledge and belief.
13A. SIGNATURE OF CLAIMANT (Sign in ink)
13B. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)

13C. DATE (MM/DD/YYYY)

SECTION III - SCHOOL OFFICIAL CERTIFICATION
14. HAS THE STUDENT MAINTAINED FULL-TIME
STATUS BY THE SCHOOL'S STANDARDS
DURING THE ENTIRE PERIOD SHOWN IN ITEM 2?
YES

NO (If "NO," complete Item 15)

16A. NAME OF SCHOOL

16B. TELEPHONE
NUMBER OF
SCHOOL OFFICIAL

(Include Area Code)

17. ENTER CLOCK HOURS ATTENDED PER WEEK IF
NOT A DEGREE GRANTING PROGRAM

15A. LIST DATES OF FULL-TIME ATTENDANCE, INCLUDING
LAST DATE OF FULL-TIME ATTENDANCE WHEN A
COURSE WITHDRAWAL IS INVOLVED (MM/DD/YYYY)

15B. IF TERM CLAIMED IN ITEM 7 HAS BEGUN,
IS STUDENT STILL FULL-TIME?
YES

16C. TYPE OF SCHOOL
COLLEGE OR UNIVERSITY

NO (If "NO," complete Item 15)
16D. TYPE OF DEGREE

TECHNICAL, TRADE, OR VOCATIONAL

OTHER
18A. SIGNATURE AND TITLE OF SCHOOL OFFICIAL (Sign in ink)

GRAD

UNDERGRAD

OTHER
18B. DATE (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 for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM
MAY 2024

21-8938-1

SUPERSEDES VA FORM 21P-8938-1, OCT 2021.

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