In order to comply with the Department of Veterans Affairs (VA) regulations, all institutions participating in the VA's education benefit program are required to obtain and use the Ds 5001 form for new and continuing students. The Ds 5001 form is a certificate of eligibility that confirms a student's enrollment status and entitlement to benefits. This form must be completed each semester by all students who receive VA educational benefits. In order to complete the form, you will need your Certificate of Eligibility (COE), which you can obtain from the VA Regional Office or online through eBenefits . If you are a veteran or dependent using VA education benefits, make sure you fill out and submit a Ds 5001 form every semester! Completing this form ensures that you continue receiving your education benefits without interruption. For more information on how to fill out and submit the Ds 5001 form, please visit our website. Thanks for choosing our school as your place of learning!
| Question | Answer |
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| Form Name | Ds 5001 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 5001 fillable, 5001 fillable form, service credit form 5001, service credit 5001 form |
U.S. Department of State
APPLICATION FOR SERVICE CREDIT
1a. |
NAME (Last, First, Middle) |
2. LIST ALL OTHER NAMES YOU HAVE USED |
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1b. |
ADDRESS (Number and Street) |
3. |
DATE OF BIRTH |
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4. SOCIAL SECURITY NUMBER |
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(City. State, and ZIP Code) |
5. |
CURRENTLY EMPLOYED BY (Check One) |
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State |
Other Agency |
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6. List below in chronological order all federal civilian service from July 1, 1924 during which no Foreign Service retirement deductions were withheld from your salary.
DEPARTMENT OR AGENCY |
LOCATION OF EMPLOYMENT |
TITLE OF POSITION |
PERIODS OF SERVICE |
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(City and State) |
Beginning Date |
Ending Date |
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7. MILITARY RECORD - List below inclusive dates of active military service (see instructions on page 2 of this form). |
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ORGANIZATION |
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RANK |
ENTRANCE INTO ACTIVE DUTY |
DATE OF HONORABLE DISCHARGE |
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DATE |
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SIGNATURE OF APPLICANT |
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PLEASE READ INSTRUCTIONS ON PAGE 2 |
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Page 1 of 2 |
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INSTRUCTIONS TO APPLICANTS
1.The filing of this Form does not obligate the applicant to purchase any past service credit for which payment may be required. Under present laws and regulations, active military service creditable for retirement purposes without cost. The applicant is required to submit an official document reflecting inclusive dates of all active military service.
2.Complete the form to the best of your recollection. Do not communicate with the Departments or Agencies involved for verification of dates of employment.
3.Complete the form in duplicate and submit the original to:
a.U.S. Department of State Office of Retirement
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2401 E. Street, NW Room H620 |
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Washington, DC |
b. Human Resource Office if employed by another agency.
4.As soon as it is possible to verify the service claimed, the applicant will be informed of any payments required to obtain credit. DO NOT SEND ANY REMITTANCE WITH THIS APPLICATION.
PRIVACY ACT STATEMENT
PURPOSES AND USES
The primary purposes of the information solicited are to support enrollment, document an election not to enroll, and/or support a present or future claim for benefits under the Foreign Service Retirement Systems, the Federal Employees' Health Benefits Program, and/or the Federal Employees' Group Life Insurance Program. The information may be shared with a) other Federal agencies, b) national, state, county, municipal, or other publicly charitable or social security administration agencies, and c) private insurance carriers providing elected benefits. It will be shared only to the extent necessary to adjudicate a benefit or determine enrollment under the programs administered by such agencies.
EFFECTS OF NONDISCLOSURE
Provision of the information requested is voluntary; however, failure to supply all of the information may delay or prevent action on your, or your survivor's enrollment or claim for benefits.
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW
Disclosure by you of your Social Security Number (SSN) is mandatory to obtain the services, benefits, or processes that you are seeking. Solicitation of the SSN by the U.S. Department of State is authorized under provisions of Executive Order 9397, dated November 22, 1943. The SSN is used as an identifier throughout your federal career from the time of application through retirement. It will be used primarily to identify your records that you file with the Department of State and other federal agencies in connection with lawful requests for information about you from your former employers, educational institutions, and financial or other organizations. The information gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with established regulations and published notices of systems of records. The SSN also will be used for the selection of persons to be included in statistical studies of personnel management matters. The use of the SSN is made necessary because of the large number of present and former federal employees and applicants who have identical names and birth dates, and whose identities can only be distinguished by the SSN.
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