Form VA Form 22-1999c VA Form 22-1999c Certificate of Affirmation of Enrollment Agreement - Cor

OMB Control No. 2900-0576
Respondent Burden: 3 Minutes
Expiration Date: XX/XX/20XX

CERTIFICATE OF AFFIRMATION OF ENROLLMENT
AGREEMENT - CORRESPONDENCE COURSE
1. FIRST NAME-MIDDLE INITIAL-LAST NAME OF ELIGIBLE PERSON

2A. VA FILE NO.

2B. E-MAIL ADDRESS OF ELIGIBLE PERSON
3. NAME OF COURSE

4. DATE ENROLLMENT
AGREEMENT SIGNED

5. NAME AND ADDRESS OF SCHOOL

PURPOSE OF THE AFFIRMATION PROVISION OF LAW
To provide you time (no less than five full days following your signing of an enrollment agreement) during which you can
reflect on your decision to enroll in a correspondence course and determine if such correspondence course is suitable to
your abilities and interests. The Correspondence School Agreement you have signed is not effective unless you complete
this form and return it to the school.

AFFIRMATION PROCEDURE:
A. Decision not to Affirm - If you decide not to affirm the Correspondence School Agreement you have signed, do not
sign this form. Destroy it. Additionally, you may notify the institution, at any time, of your decision not to affirm the
enrollment agreement. The institution, thereupon, without imposing any penalty or fee, shall make full refund of all
amounts paid.
B. Decision to Affirm - If you decide to affirm the Correspondence School Agreement you have signed, you may affirm
only after the expiration of 5 full days after the day on which the agreement was signed. For example, if the contract was
signed on the 1st day of a month, you must sign and date this affirmation certification form on or after the 7th day.

VA WILL NOT ACCEPT ANY AFFIRMATION YOU SIGN BEFORE THE 7TH DAY.
VA WILL NOT PAY FOR LESSONS THAT YOU COMPLETE AND THE SCHOOL SERVICES BEFORE
THE PROPER AFFIRMATION DATE.
TO AFFIRM, READ THE FOLLOWING PARAGRAPH AND COMPLETE ITEMS 6 AND 7 BELOW:
I have read and I understand the enrollment agreement that I entered into with the above named school on the date
indicated in Item 4. By signing this form, I affirm such enrollment agreement and certify, under penalty of law, that I have
not signed this affirmation certificate until after the expiration of 5 full days after the date I signed the aforesaid
enrollment agreement.
(SUBMIT WITH ENROLLMENT CERTIFICATION)

INSTRUCTION TO CLAIMANT: After completion of Items 6 and 7 on or after the 7th day, return VA COPY 1 and
SCHOOL COPY 2 of this form to the school identified in Item 5.
INSTRUCTION TO SCHOOL: Once the student submits VA COPY 1 and SCHOOL COPY 2 of VA Form 22-1999c to
your facility, the school should submit VA COPY 1 of VA Form 22-1999c (Certificate of Affirmation of Enrollment
Agreement - Correspondence Course) and VA Form 22-1999 (Enrollment Certification) to the Department of Veterans
Affairs.
6. DATE SIGNED

VA FORM
XXX XXXX

22-1999c

7. SIGNATURE OF ELIGIBLE PERSON

SUPERSEDES VA FORM 22-1999c, OCT 2022,
WHICH WILL NOT BE USED.

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, and 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 obligation to respond is required to obtain or retain benefits.
We cannot pay you any education benefits for taking a correspondence course 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 2900-0576, and it expires XX/XX/20XX. Public
reporting burden for this collection of information is estimated to average 3 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. 2900-0576 in any correspondence. Do
not send your completed VA Form 22-1999c to this email address.

VA FORM 22-1999c, XXX XXXX

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