Va Form 21 674 – Fill Out and Use This PDF

Enter the VETERAN/CLAIMANT'S NAME (First, Middle Initial, Last), the VA FILE NUMBER (If applicable) and the E-MAIL ADDRESS (Optional).

Enter the STUDENT'S NAME (First, Middle Initial, Last) of the veteran's child attending school, the SOCIAL SECURITY NUMBER and the DATE OF BIRTH (MM/DD/YYYY).

If you would like to submit an additional student's information, use a separate form (VA Form 21-674) for each student.

HAS STUDENT EVER MARRIED? YES (If "Yes," complete Item 7B) or NO. Enter the DATE OF MARRIAGE (MM/DD/YYYY) in Item 7B.

Enter the ADDRESS OF STUDENT (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country): No. & Street, City, Apt./Unit Number, State/Province, ZIP Code/Postal Code and Country.

Answer "Yes" to Item 9A only if the student is in receipt of educational assistance under 38 U.S.C. Chapter 35 (also known as Chapter 35, Dependent's Educational Assistance, or DEA), the Fry Scholarship under 38 U.S.C. 3311, or the Federal Employees' Compensation Act (FECA). Or if the student is enrolled in an educational program in a school where the child is wholly supported at the expense of the Federal government.

If Item 9A is YES, complete Item 9B, TYPE OF PROGRAM OR BENEFIT (i.e. Chapter 35, Fry Scholarship, FECA, Service Academy or Preparatory School, Federally funded Native American School, Job Corps program), and Item 9C, DATE PAYMENTS BEGAN (MM/DD/YYYY), and enter the name of the Federally funded school or program. If NO, skip to Item 10A. Do not report receipt of Post-9/11 GI Bill under 38 U.S.C. chapter 3319 (also known as transferred GI Bill benefits) in Item 9A.

A student is wholly supported at the expense of the Federal government when the Federal government pays for the student's tuition, housing, meals, suitable clothing, medical attention, books, supplies and other necessities.

Examples of programs or schools that are wholly supported by the Federal government include service academies, service academy preparatory schools, Job Corps centers, and some Native American schools.

MY DEPENDENT HAS ATTENDED SCHOOL CONTINUOUSLY: YES (If "Yes," complete Item 10B) or NO (If "No," add the date your dependent stopped attending continuously) (MM/DD/YYYY). Normal breaks during the school year are not considered breaks in continuous enrollment.

IS THE SCHOOL ACCREDITED? YES or NO.

Enter the OFFICIAL BEGINNING DATE OF REGULAR TERM OR COURSE, the DATE STUDENT STARTED OR EXPECTS TO START COURSE and the EXPECTED DATE OF GRADUATION (MM/DD/YYYY).

WAS STUDENT ATTENDING AN ACCREDITED SCHOOL AT END OF LAST SCHOOL TERM? YES (If "Yes," complete Items 12B and 12C) or NO.

Enter the BEGINNING DATE OF LAST TERM and the ENDING DATE OF LAST TERM (MM/DD/YYYY).

Complete this part only if the benefit being claimed or received is disability Pension or Survivors' Pension.

13. Report of income by calendar year (Do NOT report VA benefits). A. Source: earnings from all employment, annual Social Security, other annuities and all other income (i.e. interest, dividends, etc.). B. Received: report for year in which school term begins (See Item 11). C. Expected: report for year following Column B.

Each income block must be completed. If you do not receive income from a particular source, write "0.00" in the boxes provided. Do not leave the space blank. VA will interpret a blank space as "0" or "None". Report the gross amounts before you take out deductions for taxes, insurance, etc. Do not report receipt of Post-9/11 GI Bill under 38 U.S.C. chapter 3319 in Item 9A.

Improved Pension: Complete this part showing the student's income.

Enter the 14. VALUE OF ESTATE: A. SAVINGS (Including cash), B. SECURITIES, BONDS, ETC., C. REAL ESTATE (Not your home), D. ALL OTHER ASSETS and E. TOTAL VALUE.

15. REMARKS (If any): report the total amount(s) paid and dates of payment of educational or vocational rehabilitation expenses in Section V: Remarks. These expenses are amounts paid by the student for their course of post-secondary education or vocational rehabilitation, including tuition, fees, and materials. If any of these expenses are paid by the student, the expenses may be deducted from the earned income of the student.

Enter 16A. VETERAN/CLAIMANT/STUDENT SIGNATURE (REQUIRED), 16B. DATE SIGNED (MM/DD/YYYY), 16C. RELATIONSHIP TO STUDENT, 16D. TELEPHONE NUMBER (Include Area Code) and the International Phone Number (If applicable).

You certify that the information given on this form is true and correct to the best of your knowledge and belief and request approval of the education or training shown on this form.

You agree to notify the Department of Veterans Affairs immediately of any changes in your education, transfer to another school, discontinuance of school attendance, receipt of DEA, or marriage prior to completion of your education.

You understand that continued entitlement to school attendance may be based on information you have furnished on this form.

Receipt by the student of VA Dependents' Educational Assistance (DEA), the Federal Employee's Compensation Act, or benefit from another Federal Agency (i.e. U.S. Service Academy, U.S. Merchant Marine Academy, Bureau of Indian Affairs, etc.) with additional compensation payments based on the student's school attendance is considered a duplication of benefits and is prohibited.

COMPENSATION CLAIMS: Department of Veterans Affairs Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444. PENSION & SURVIVORS BENEFIT CLAIMS: Department of Veterans Affairs Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365. Read the instructions carefully before completing this form. Use VA Form 21-674b, School Attendance Report, to report to VA any change in the child's status, such as termination of school attendance or marriage.

The law provides severe penalties (including fine or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or for fraudulent receipt of any document you are not entitled to.