Form 22-10215a Statement of Assurance of Compliance with 85 Percent Enr

STATEMENT OF ASSURANCE OF COMPLIANCE WITH 85 PERCENT ENROLLMENT RATIOS CONTINUATION SHEET
GENERAL INFORMATION
Use this form (VA Form 22-10215a) to provide additional 85/15 calculations as required by Title 38 United States Code (U.S.C.) 3680A(d) and 38 Code of Federal
Regulations (CFR) 21.4201.
This form can only be submitted when attached to a completed STATEMENT OF ASSURANCE OF COMPLIANCE WITH 85 PERCENT ENROLLMENT RATIOS,
VA FORM 22-10215.

INFORMATION AND INSTRUCTIONS
VA EDUCATION SERVICE HELP AVAILABLE - If you need help calculating your facility's compliance with the 85/15 rule, require assistance submitting routine
reports, or have questions concerning the 85/15 rule, contact the Education Liaison Representative of jurisdiction.

NOTE: The requirements of this form match those provided on STATEMENT OF ASSURANCE OF COMPLIANCE WITH 85 PERCENT ENROLLMENT RATIOS,
VA Form 22-10215. See the instruction sheet for STATEMENT OF ASSURANCE OF COMPLIANCE WITH 85 PERCENT ENROLLMENT RATIOS, VA Form
22-10215 if additional clarification is required while completing this form.

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 (e.g., VA sends 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 obligation to respond is required to obtain or retain education benefits. The responses you provide are considered confidential (38 U.S.C. 5701). Any
information provided by applicants, recipients, and others 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 2900-0897, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 1 hour 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. 2900-0897 in any correspondence. Do not send your completed VA Form 22-10215a to this email address.

VA FORM
XXX 20XX

22-10215a

Page 1

OMB Approved No. 2900-0897
Respondent Burden: 1 hour
Expiration Date: XX/XX/20XX

STATEMENT OF ASSURANCE OF COMPLIANCE WITH 85 PERCENT ENROLLMENT RATIOS CONTINUATION SHEET
1. INSTITUTION NAME

2. FACILITY CODE

3. TERM START DATE

4. CALCULATION DATE

5. 85/15 PERCENT CALCULATION
5A. PROGRAM NAME

5B. TOTAL NUMBER
OF STUDENTS
ENROLLED

5C. TOTAL NUMBER
OF SUPPORTED
STUDENTS
ENROLLED

5D. NUMBER OF
SUPPORTED
STUDENTS FTE

5E. NUMBER
OF NON-SUPPORTED
STUDENTS
FTE

5F. TOTAL
ENROLLED
FTE

5G. SUPPORTED
STUDENT
PERCENTAGE FTE

This is page ___ of ___ additional Statement of Assurance of Compliance with 85 Percent Enrollment Ratios Continuation Sheet(s) provided.
I HEREBY CERTIFY THAT the calculations listed above are true and correct in content and policy.
6. SCHOOL OFFICIAL PRINTED NAME
8. SIGNATURE OF SCHOOL OFFICIAL
VA FORM
XXX 20XX

22-10215a

7. SCHOOL OFFICIAL TITLE
9. DATE SIGNED
Page 2