Form 22-1990 Application for Education Benefits

APPLICATION FOR VA EDUCATION BENEFITS
(VA FORM 22-1990)
Use this form to apply for educational assistance under the following benefit programs:
• Post- 9/11 GI Bill chapter 33 of title 38, U.S. Code
• Montgomery GI Bill (MGIB) chapter 30 of title 38, U.S. Code
• Montgomery GI Bill - Selected Reserve (MGIB-SR) chapter 1606 of title 10, U.S. Code
• Post-Vietnam Era Veterans' Educational Assistance Program (VEAP) chapter 32
of title 38, U.S. Code, or section 901 or section 903 of Public Law 96-342

INFORMATION AND INSTRUCTIONS
FOR COMPLETING THE APPLICATION FOR VA EDUCATION BENEFITS
Do not use this form to apply for Vocational Rehabilitation and Employment benefits (chapter 31 of title 38, U.S. Code), Dependents Educational
Assistance benefits (chapter 35 of title 38, U.S. Code), Marine Gunnery Sergeant John David Fry Scholarship (chapter 33 of title 38, U.S. code),
Transfer of Entitlement, or National Call to Service (section 510 of title 10, U.S. Code). These benefits require different application forms that can be
completed on-line and printed at www.va.gov/vaforms or can be obtained from the nearest VA regional office. They may also be available where you
received this application.
INTERNET VERSION AVAILABLE - You may complete and submit this application on-line at www.benefits.va.gov/gibill. Click "Apply
On Line" and select the "Education" option.
VA VOCATIONAL AND EDUCATIONAL COUNSELING HELP AVAILABLE - If you need help planning your individual
educational and career goals, VA offers a wide range of counseling services to help you make these decisions. Services include educational
and vocational guidance and such testing as necessary for you to develop a greater understanding of your skills, talents, and interests. For further
information on VA counseling, call VA toll-free at 1-888-GI-BILL-1 (1-888-442-4551) or TDD at the Federal Relay, 711.
PART I
NOTE: The numbers on the instructions match the item numbers on the application. Items not mentioned are self-explanatory.
This section provides an overview of the general eligibility requirements for various education programs. Additional requirements not listed on this
form may be necessary.
NOTE: A specific single period of service may not be used towards establishing eligibility for more than one benefit. Therefore, once a period of
service has been applied toward a specific benefit, that period of service may not be used again toward a different benefit. However, there is one
exception to this rule. With regard to Chapter 33, a period of service beginning before August 1, 2011, can be used to establish eligibility to Chapter 33
even if it has already been used to establish eligibility to a different benefit.
ITEM 7. The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit
(Direct Deposit is not available for Chapter 32 recipients). To enroll in direct deposit, provide the information requested in Item 7 and attach either a
voided personal check or a deposit slip to match the information in Item 7. If you do not have a bank account, please visit https://
www.benefits.va.gov/benefits.banking.asp. This website provides information about the Veterans Benefits Banking Program (VBBP), and a link to
banks and credit unions that may fit your needs. You may also call 1-800-827-1000. If you elect not to enroll, you must contact representatives
handling waiver requests for the Department of the Treasury at 1-888-224-2950. They will encourage your participation in EFT and address any
questions or concerns you may have.
PART II
ITEM 9A. You may be eligible for benefits under the Post-9/11 GI Bill, also referred to as chapter 33, if you served at least 90 aggregate
days on active duty (excluding entry level and skill training) after September 10, 2001. You may also qualify if you were discharged due to
a service-connected disability after serving at least 30 continuous days on active duty after September 10, 2001.
ITEM 9B. You may be eligible for the Montgomery GI Bill, also referred to as MGIB or chapter 30, if you served on active duty and meet certain
conditions. NOTE: You do not have to be on active duty to apply for benefits under this program. You must meet any one of the following conditions
(there are additional requirements):
You first entered service on or after July 1, 1985, and you didn't decline this benefit at your initial entry into service
OR
You entered service (or agreed to delayed entry) before January 1, 1977, and you have educational assistance entitlement remaining under
the Vietnam Era GI Bill (also known as "chapter 34")
OR
You were voluntarily separated under the Voluntary Separation Incentive (VSI) or Special Separation Benefit (SSB) programs and had
your military pay reduced by $1,200
OR
You were involuntarily separated from active duty after February 2, 1991
OR
You were on active duty and a participant in the Post-Vietnam Era Veterans' Educational Assistance Program (VEAP) program on or before October 9,
1996, or you first entered the National Guard under title 32, U.S. Code, between July 1, 1985, and November 28, 1989, you elected chapter 30 benefits
between October 9, 1996, and October 8, 1997, and you paid $1,200
OR
You were on active duty and eligible for VEAP benefits on October 9, 1996, you elected chapter 30 benefits between November 1, 2000,
and October 31, 2001, and you paid $2,700.
VA FORM
XXX XXXX

22-1990

SUPERSEDES VA FORM 22-1990, JUN 2024,
WHICH WILL NOT BE USED.

PAGE 1

ITEM 9C. You may be eligible for the Montgomery GI Bill - Selected Reserve Educational Assistance Program, also known as MGIB-SR or chapter
1606, if you are a member of the Selected Reserve and meet certain requirements, including a 6-year commitment. (The Departments of Defense and
Homeland Security determine eligibility for this program.)
To expedite processing, attach a copy of your DD 2384, Selected Reserve Educational Assistance Program (GI BILL) Notice of Basic Eligibility. This
form is also called a "NOBE." Your reserve unit should have issued this notice to you when you became eligible for the Montgomery GI Bill - Selected
Reserve Educational Assistance Program. If you are unable to locate your copy, request a duplicate from your reserve unit.
ITEM 9D. You may be eligible for benefits under the Post-Vietnam Era Veterans' Educational Assistance Program (VEAP), also known as Chapter
32, if your service began on or after January 1, 1977, and before July 1, 1985, and you contributed to a VEAP account.
You may be eligible for benefits under the Post-Vietnam Era Non-Contributory Veterans' Educational Assistance Program, also known as "NonContributory VEAP" or Section 903", if your service began on or after November 30, 1980, and before October 1, 1981, and your branch of service
paid contributions into your VEAP account.
PART III
ITEM 10A. Self-explanatory, except for the following items:
"Vocational Flight Training." You must already have a private pilot's license. If you are taking an Airline Transport Pilot course, you must have a valid
first-class medical certificate on the date that you enter training. For all other flight courses, you must have a valid second-class medical certificate on
the date that you enter training.
"National Test Reimbursement." You can be reimbursed for the cost of approved tests for admission to, or credit at, institutions of higher learning.
"Licensing or Certification Test Reimbursement." A licensing test is a test offered by a state, local, or federal agency that is required by law to practice
an occupation. A certification test is a test designed to provide affirmation of an individual's qualifications in a specific occupation. Examples include
EMT, CPA, MCSE, CCNP, etc.
"Tuition Assistance Top-Up." This benefit is payable only under MGIB and the Post-9/11 GI Bill programs. You can receive benefits to pay for the
difference between what the military pays with Tuition Assistance (TA) and the total costs of these courses.
PART VIII
QUESTIONS ARE ONLY FOR APPLICANTS WHOSE SERVICE BEGAN BEFORE JANUARY 1, 1977, (or delayed entry before January 2, 1978). If
you are currently married or if you have children under age 18 (under age 23 if in school), you should complete and return VA Form 21-686c. If your
children are in school, you should also complete and return VA Form 21-674 for each child. If your parent(s) are dependent on you for financial
support, you should complete and return VA Form 21-509. These forms may require additional documentation. VA cannot pay any additional benefits
for dependents without properly completed forms and documentation. You can find VA forms 21-686c, 21-674, and 21-509 on-line at www.va.gov/
vaforms.
ITEM 24. If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or
your spouse resided at the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later date when you became
eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on when VA recognizes marriages is available at www.va.gov/opa/marriage.
ADDITIONAL HELP
If you need more help in completing this application, call VA TOLL FREE at 1-888-GI-BILL-1 (1-888-442-4551). If you use the Telecommunications
Device for the Deaf (TDD), the Federal Relay number is 711. You can also get education assistance after normal business hours at our education
Internet site www.benefits.va.gov/gibill.
HOW TO FILE YOUR CLAIM
Be sure to do the following:
(A) If you have selected a school or training establishment:
Step 1. Mail the completed application to the VA Regional Processing Office for the state or region of that school's physical address. See page 3 for the
addresses of VA Regional Processing Offices.
Step 2. Tell the veterans certifying official at your school or training establishment that you have applied for VA education benefits. Ask him or her to
send your enrollment information using VA Form 22-1999, Enrollment Certification, or its electronic version.
Step 3. Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.
(B) If you haven't selected a school or training establishment:
Step 1: Mail the completed application to the VA Regional Processing Office for the state or region of your home address. See the addresses below for
VA Regional Processing Offices.
Step 2: Wait for VA to process your application and notify you of its decision concerning your eligibility for education benefits.

VA FORM 22-1990, XXX XXXX

PAGE 2

Eastern Region:
VA Regional Office
P.O. Box 4616
Buffalo, NY 14240-4616
SERVES THE FOLLOWING STATES

CO

CT

DC

DE

IA

IL

IN

KS

KY

MA

MD

ME

MI

MN

MO

MT

NC

ND

NE

NH

NJ

NY

OH

PA

RI

SD

TN

VA

VT

WI

WV

WY

APO / FPO AA

FOREIGN SCHOOLS

US VIRGIN ISLANDS

Western Region:
VA Regional Office
P.O. Box 8888
Muskogee, OK 74402-8888
SERVES THE FOLLOWING STATES

AK

AL

AR

AZ

CA

FL

GA

HI

ID

LA

MS

NM

NV

OK

OR

PR

SC

TX

UT

WA

APO / FPO AP

GUAM

PHILIPPINES

AMERICAN SAMOA

MARIANA ISLANDS

REQUEST TO OPT OUT OF INFORMATION SHARING WITH EDUCATIONAL INSTITUTIONS
The Harry W. Colmery Veterans Educational Assistance Act of 2017 (Public Law 115-48), also know as the "Forever GI Bill," requires the
Department of Veterans Affairs (VA) to make available to educational institutions information about the amount of educational assistance to which a
veteran or other eligible individual is entitled. If you are eligible for the Post-9/11 GI Bill (Chapter 33), Montgomery GI Bill-Active Duty
(Chapter 30), Montgomery GI Bill - Selected Reserve (Chapter 1606), or the Survivors' and Dependents Educational Assistance Program (DEA)
(Chapter 35), you may elect to "opt-out" of these disclosures and have VA withhold this information instead. To request an opt-out, or for information
about how to opt-out, please refer to our website at va.gov, or click https://www.va.gov/find-forms/ to complete the VA Form 22-0993, Request to
Opt-Out of Information Sharing with Educational Institutions.
Privacy Act Notice: 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, section 1.576 for routine uses (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 the VA to obtain further information as may be necessary from the school
for the VA to properly process the veteran's education claim or to monitor his or her progress during training) as identified in the VA system of records, 58VA21/22/28,
Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, and published in the Federal Register. Your response is required to obtain or
retain education benefits. Giving us your SSN account information is voluntary. 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 enacted before January
1, 1975, and still in effect. The requested information is considered relevant and necessary to determine the maximum benefits under the law. While you do not have to
respond, VA cannot process your claim for education assistance unless the information is furnished as required by existing law (38 U.S.C. 3471). The responses you
submit are considered 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 2900-0154, and it expires XX/XX/20XX. Public reporting burden for this collection of information is
estimated to average 15 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.
2900-0154 in any correspondence. Do not send your completed VA Form 22-1990 to this email address.

VA FORM 22-1990, XXX 20XX

PAGE 3

OMB Control No. 2900-0154
Respondent Burden: 15 minutes
Expiration Date: XX/XX/20XX

APPLICATION FOR VA EDUCATION BENEFITS
(See attached Information and Instructions)

INTERNET VERSION AVAILABLE - You may complete and send your application over the Internet at: www.benefits.va.gov/gibill.

PART I - APPLICANT INFORMATION
2. GENDER OF APPLICANT

1. SOCIAL SECURITY NUMBER OF APPLICANT

FEMALE

MALE

3. APPLICANT'S DATE OF BIRTH
Month

Day

Year

4. NAME (First, Middle Initial, Last)

5. APPLICANT'S ADDRESS
Number and Street
Apt./Unit Number
City, State, ZIP Code
6A. APPLICANT'S TELEPHONE NUMBERS (Include Area Code)
Mobile:

Home:
6B. APPLICANT'S E-MAIL ADDRESS (Required)

7. DIRECT DEPOSIT (To enroll in direct deposit, attach a voided personal check or deposit slip to match the information provided below. Direct Deposit is not available for Chapter 32
recipients. See Instructions for additional Direct Deposit information.)

Routing or Transit Number

Account Type
Checking

Account Number

Savings

8. PLEASE PROVIDE THE NAME, ADDRESS, AND PHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED

A. NAME

B. ADDRESS

C. PHONE NUMBER

PART II - EDUCATION BENEFITS BEING APPLIED FOR

For help with completing this section, please see the attached instructions page or visit our website at www.benefits.va.gov/gibill
9A. Chapter 33 - Post-9/11 GI Bill
9B. Chapter 30 - Montgomery GI Bill Educational Assistance Program (MGIB)
9C. Chapter 1606 - Montgomery GI Bill - Selected Reserve Educational Assistance Program (MGIB-SR)
9D. Chapter 32 or Section 903 - Post-Vietnam Era Veterans' Educational Assistance Program (VEAP)

VA DATE STAMP
(Do Not Write In This Space)

VA FORM
XXX 20XX

22-1990

SUPERSEDES VA FORM 22-1990, JUN 2024,
WHICH WILL NOT BE USED.

PAGE 4

SOCIAL SECURITY NUMBER OF APPLICANT

PART III - TYPE AND PROGRAM OF EDUCATION OR TRAINING
10A. TYPE OF EDUCATION OR TRAINING (See instructions for additional information)
COLLEGE OR OTHER SCHOOL (Including on-line courses)

APPRENTICESHIP OR ON-THE-JOB

VOCATIONAL FLIGHT TRAINING

CORRESPONDENCE

NATIONAL TEST REIMBURSEMENT (SAT, CLEP, ETC.)

TUITION ASSISTANCE TOP-UP
(Chapter 30 & 33 only)

LICENSING OR CERTIFICATION TEST REIMBURSEMENT
(MCSE, CCNA, EMT, NCLEX, ETC.)

10B. PROVIDE THE FULL NAME AND ADDRESS OF THE SCHOOL, IF KNOWN (Skip this item if you are only applying for National Test Reimbursement, Licensing and
Certification Test Reimbursement, or Tuition Assistance Top-Up)

10C. PLEASE SPECIFY YOUR EDUCATIONAL OR CAREER OBJECTIVE, IF KNOWN (e.g. Bachelor of Arts in Accounting, welding certificate, police officer, etc.)

PART IV - SERVICE INFORMATION
NOTE: It will help VA process your claim if you send a copy of the following:
• DD Form 214 (Member 4) for all periods of active duty service (excluding active duty for training)
• DD Form 2384, Notice of Basic Eligibility (NOBE) if applying for Chapter 1606
• Copies of orders if activated from the Guard/Reserves
11. ARE YOU ON ACTIVE DUTY? (Do not check "Yes" if you are currently on drilling status in the Selected Reserve, or if you are on active duty for training)
YES

NO

12. ARE YOU NOW ON TERMINAL LEAVE JUST BEFORE DISCHARGE?
YES

NO

(Please provide a copy of your DD Form 214 (Member 4) when issued)

13. PLEASE COMPLETE THE FOLLOWING FOR EACH PERIOD OF MILITARY SERVICE
A. DATE ENTERED

B. DATE SEPARATED

C. SERVICE COMPONENT (USN,
USAF, USAR, ARNG, etc.)

9/26/2000
1/18/2005

9/24/2004
8/14/2007

USMC
USMCR

D. SERVICE STATUS (Active duty,
drilling reservist, IRR, etc.)

EXAMPLES

E. WERE YOU INVOLUNTARILY CALLED TO
ACTIVE DUTY FOR THIS PERIOD?

ACTIVE DUTY
DRILLING

NO
N/A

PART V - EDUCATION AND EMPLOYMENT INFORMATION
14. DID YOU RECEIVE A HIGH SCHOOL DIPLOMA OR HIGH SCHOOL
EQUIVALENCY CERTIFICATE? (If "Yes" provide date)
YES

DATE:

VA FORM 22-1990, XXX 20XX

NO

14A. DO YOU HOLD ANY FAA FLIGHT CERTIFICATES? (If "Yes," specify each
certificate in Part IX, Remarks)
YES

NO

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SOCIAL SECURITY NUMBER OF APPLICANT

14B. EDUCATION AFTER HIGH SCHOOL (Including apprenticeship, on-the-job training, and flight training)
NAME AND LOCATION OF COLLEGE
OR OTHER TRAINING PROVIDER

DATES OF TRAINING
FROM

TO

NUMBER AND TYPE
OF HOURS
(Semester, Quarter, or Clock)

DEGREE, DIPLOMA,
OR CERTIFICATE
RECEIVED

MAJOR FIELD
OR COURSE OF STUDY

14C. EMPLOYMENT (Only complete if you held a license or journeyman rating to practice a profession)
EMPLOYMENT

PRINCIPAL OCCUPATION

NUMBERS OF MONTHS
WORKED

LICENSE OR RATING

BEFORE MILITARY SERVICE

AFTER MILITARY SERVICE

PART VI - ENTITLEMENT TO AND USAGE OF ADDITIONAL TYPES OF ASSISTANCE
15. DID YOU MAKE ADDITIONAL CONTRIBUTIONS (UP TO $600.00) TO INCREASE THE AMOUNT OF YOUR MONTHLY
BENEFITS? IF "YES," IT WILL HELP VA PROCESS YOUR CLAIM IF YOU SUBMIT ANY EVIDENCE YOU HAVE TO
SUPPORT YOUR CLAIM (e.g., cash collection voucher, leave and earnings statement(s), receipt voucher, etc.)
16. DO YOU QUALIFY FOR A KICKER (sometimes called a "College Fund") BASED ON YOUR MILITARY SERVICE?
(Kickers are additional amounts contributed by DOD to an education fund). If you qualify for a kicker, it will help VA
process your claim if you submit a copy of the kicker contract. Reserve kicker contracts must include the amount and
effective date.
17. IF YOU GRADUATED FROM A MILITARY SERVICE ACADEMY, SPECIFY THE YEAR YOU GRADUATED AND
RECEIVED YOUR COMMISSION.
18. WERE YOU COMMISSIONED AS THE RESULT OF A SENIOR ROTC (Reserve Officers Training Corps) SCHOLARSHIP?
If you received your commission through a non-scholarship program, check "No." If "Yes," provide the date of your
commission and the amount of your scholarship for each school year you were in the Senior ROTC program. Don't report
your monthly subsistence allowance (stipend).
Scholarship Amounts:

YES

NO

ACTIVE DUTY KICKER
YES

NO

RESERVE KICKER
YES

NO

Graduation Year

YES

NO

Date of Commission

Year:

Amount:

Year:

Amount:

Year:

Amount:

Year:

Amount:

Year:

Amount:

19. ARE YOU CURRENTLY PARTICIPATING IN A SENIOR ROTC SCHOLARSHIP PROGRAM THAT PAYS FOR YOUR
TUITION, FEES, BOOKS AND SUPPLIES UNDER SECTION 2107 OF TITLE 10, U.S. CODE?

YES

NO

20. IF YOU HAD A PERIOD OF ACTIVE DUTY THAT THE DEPARTMENT OF DEFENSE COUNTS FOR PURPOSES OF
REPAYING AN EDUCATION LOAN, CHECK "YES". SHOW THE PERIOD OF ACTIVE DUTY THAT THE MILITARY
CONSIDERS AS BEING USED FOR THE PURPOSES OF REPAYING THIS EDUCATION LOAN IN PART IX "REMARKS".

YES

NO

YES

NO

YES

NO

21. FOR ACTIVE DUTY CLAIMANTS ONLY: ARE YOU RECEIVING, OR DO YOU ANTICIPATE RECEIVING, ANY MONEY
(INCLUDING BUT NOT LIMITED TO FEDERAL TUITION ASSISTANCE) FROM THE ARMED FORCES OR PUBLIC
HEALTH SERVICE FOR THE COURSE FOR WHICH YOU HAVE APPLIED TO THE VA FOR EDUCATION BENEFITS? IF
YOU RECEIVE SUCH BENEFITS DURING ANY PART OF YOUR TRAINING, CHECK "YES." NOTE: IF YOU ARE ONLY
APPLYING FOR TUITION ASSISTANCE TOP-UP, CHECK NO IN THIS ITEM.
22. FOR CIVILIAN EMPLOYEES OF THE U.S. GOVERNMENT ONLY: ARE YOU RECEIVING, OR DO YOU ANTICIPATE
RECEIVING, ANY MONEY (INCLUDING, BUT NOT LIMITED TO, THE GOVERNMENT EMPLOYEES TRAINING ACT)
FROM YOUR AGENCY FOR THE SAME PERIOD FOR WHICH YOU HAVE APPLIED TO THE VA FOR EDUCATION
BENEFITS? IF YOU WILL RECEIVE SUCH BENEFITS DURING ANY PART OF YOUR TRAINING, CHECK "YES."
VA FORM 22-1990, XXX 20XX

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SOCIAL SECURITY NUMBER OF APPLICANT

PART VII - INFORMATION ON VA EDUCATION BENEFITS
NOTE: The most current information on VA education benefits is available online at www.benefits.va.gov/gibill.
If you would like to receive a printed pamphlet check here.

PART VIII - MARITAL AND DEPENDENCY STATUS
NOTE: Only complete this section if you have military service before January 1, 1977 (or delayed entry before January 2, 1978). See instructions.
23. ARE YOU MARRIED?
YES

NO

24. DO YOU HAVE ANY CHILDREN WHO ARE UNDER AGE 18, OR OVER 18 BUT UNDER AGE 23, NOT MARRIED AND ATTENDING SCHOOL, OR OF ANY AGE
PERMANENTLY HELPLESS FOR MENTAL OR PHYSICAL REASONS?
YES

NO

25. DO YOU HAVE A PARENT WHO IS DEPENDENT UPON YOU FOR FINANCIAL SUPPORT?
YES

NO

PART IX - REMARKS

(If more space is needed, please attach a separate sheet of paper. Be sure to include your name and social security number on each sheet)

APPLICATION SUBMISSION REMINDERS
Did you remember to ........
• Write your social security number on each page?
• Write your complete mailing address and email address?
• Attach all supporting documents (e.g. voided check, orders, DD214, kicker contract, NOBE, cash collection voucher, etc.)?
• Check only one of the boxes below Item 9F of the benefit you are relinquishing in order to receive Chapter 33?
IF SO, PLEASE SIGN AND DATE THE APPLICATION BELOW

PART X - CERTIFICATION AND SIGNATURE OF APPLICANT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief. If on active duty, I also certify that I
have consulted with an Education Service Officer (ESO) regarding my education program.
PENALTY - Willful false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the forfeiture of
these or other benefits and in criminal penalties.
26A. SIGNATURE OF APPLICANT (DO NOT PRINT)

VA FORM 22-1990, XXX 20XX

26B. DATE SIGNED (MM/DD/YYYY)

PAGE 7