Va Form 21 674 – Fill Out and Use

IMPORTANT - Be sure to read the Instructions on the reverse of Copy 1 before completing this form. The form should be completed in duplicate and signed in Part III.

PART I - TO BE COMPLETED BY CLAIMANT (Also sign certification in Part III)

2A. FIRST NAME-MIDDLE INITIAL-LAST NAME OF VETERAN (Type or Print)

2B. E-Mail ADDRESS OF VETERAN (If

3. VA FILE NUMBER

applicable)

C/CSS

4A. FIRST NAME-MIDDLE INITIAL-LAST NAME OF STUDENT (Veteran's child attending school) (Type or print)

4B. STUDENT'S SOCIAL SECURITY NUMBER

5A. DATE OF BIRTH

5B. HAS STUDENT EVER MARRIED?

5C. DATE OF MARRIAGE

YES

NO

(If "Yes," complete Item 5C)

6. ADDRESS OF STUDENT (Number and street or rural route, city

7A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID BY

or P.O., State and Zip Code)

VA DEPENDENTS EDUCATIONAL ASSISTANCE (DEA), THE FEDERAL EMPLOYEE'S

COMPENSATION ACT OR ANY OTHER AGENCY OR PROGRAM OF THE UNITED STATES

GOVERNMENT?

YES

NO (If "Yes," complete Items 7B and 7C. If "No," skip to Item 8A)

7B. AGENCY NAME

7C. DATE PAYMENTS BEGAN (Month, day, year)

11A. WAS STUDENT ATTENDING ANY SCHOOL AT END OF	11B. NAME AND ADDRESS OF SCHOOL ATTENDED LAST TERM
LAST SCHOOL TERM?

		YES		NO (If "Yes," complete Items 11B thru 11F)
11C. NO. OF SESSIONS					11D. HOURS PER WEEK	11E. BEGINNING DATE OF LAST TERM	11F. ENDING DATE OF LAST TERM
		PER WEEK

PART II - STUDENT'S INCOME AND NET WORTH (See instructions on reverse for when required)

12. REPORT OF INCOME BY CALENDAR YEAR (IMPORTANT - Do NOT report VA benefits)

13. VALUE OF ESTATE

B. RECEIVED

C. EXPECTED

A. SAVINGS

(Report for year following

A. SOURCE

(REPORT FOR YEAR IN WHICH SCHOOL

$

(Including cash)

TERM BEGINS-SEE ITEM 9 ABOVE)

that shown in Column B)

EARNINGS FROM

B. SECURITIES, BONDS,

ALL EMPLOYMENT

ETC.

ANNUAL SOCIAL

C. REAL ESTATE

SECURITY

(Not your home)

OTHER

D. ALL OTHER ASSETS

ANNUITIES

ALL OTHER INCOME

E. TOTAL OF ABOVE

$

(Interest, dividends, etc.)

14. REMARKS

PART III - CERTIFICATION AND AGREEMENT TO BE SIGNED BY CLAIMANT

NOTE: This part will be completed by the student only if he or she has attained majority and is claiming benefits in his or her own right. Otherwise, the veteran, surviving spouse, guardian or custodian will sign and also enter his or her relationship to the student.

Receipt by the student of VA Dependents Educational Assistance (DEA), the Federal Employee's Compensation Act, or benefit from another Federal Agency (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.

I CERTIFY THAT the information given above is true and correct to the best of my knowledge and belief and request approval of the course of education or training shown above.

I AGREE to notify the Department of Veterans Affairs immediately of any changes in this course of education, transfer to another school, discontinuance of school attendance, receipt of Dependents Educational Assistance, or marriage prior to completion of the course. I understand that continued entitlement to school attendance may be based on information I have furnished on this form. Any benefits allowed due to this certification will be discontinued if the student marries, receives VA Dependents Education Assistance (DEA) benefits, leaves school, or passes away.

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false.

VA FORM	21-674	SUPERSEDES VA FORM 21-674, APR 2015.
JUN 2018

INSTRUCTIONS

NOTE: Read the instructions carefully before completing this form.

How do I complete VA Form 21-674?

VA Form 21-674 should be completed by the person receiving or claiming benefits for a veteran's child who is at least 18 but under 23 and attending school. The veteran's child should complete the form only if he or she has reached the age of majority and is or will be entitled to receive direct payment of VA benefits. NOTE: The age of majority is determined by State law; it is age 18 in most states.

Print all answers clearly. For additional space, attach a separate sheet, indicating the item number to which the answers apply. Make sure to write the veteran's name and VA claim number on any attachments to this form.

Submit the original copy (VA File Copy 1) of the completed form to the VA office shown in Item 1. If no address is shown, mail or take it to the nearest VA regional office. Keep Claimant's Copy 2 for your own records and use the reverse, School Attendance Report, to report to VA any change in the child's status, such as termination of school attendance or marriage.

PART I

All claimants must complete this part. Answer "Yes" to Item 7A only if Federal Employee's Compensation, VA Dependents Educational Assistance (DEA), or another Federal Agency (U.S. Service Academy, U.S. Merchant Marine Academy, Bureau of Indian Affairs, etc.) is paying the student's tuition. Do not answer "Yes" simply because Social Security benefits have been awarded based on the student's continuing school attendance.

PART II

Complete this part only if the benefit being claimed or received is disability pension or death pension. Each income block must be completed. If you do not receive income from a particular source, write "0" or "none" in the space 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.

Section 306 or Old Law Pension (entitlement to pension established before January 1, 1979): Complete this part only if the VA benefit payable will be death pension, and there is no surviving spouse entitled to death pension. Do not complete if the student is a dependent on a veteran's or surviving spouse's award.

Improved Pension: Complete this part showing the student's income. Educational or vocational rehabilitation expenses are amounts paid by the student for his or her 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. Report the total amount(s) paid and dates of payment in Item 14, "Remarks."

PART III

This part will be completed by the student only if he or she has reached the age of majority and is claiming benefits in his or her right. Otherwise, the veteran, surviving spouse, guardian or custodian will sign and also enter his or her relationship to the student in Item 16.

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 (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. the requested information is considered relevant and necessary to determine maximum benefits under the law. Giving us your and your dependents' SSN account information is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 U.S.C. 5101(c)(1). 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 in effect prior to January 1, 1975, and still in effect. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

Respondent Burden: We need this information to determine entitlement to benefits for a veteran's child who is between age 18 and 23 and attending school (38 U.S.C. 104(a)). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain . If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-674, JUN 2018

OMB Approved No. 2900-0049 Respondent Burden: 5 minutes Expiration Date: 06/30/2021

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 (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested information is considered relevant and necessary to determine maximum benefits under the law. Giving us your and your dependents' SSN account information is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 U.S.C. 5101(c)(1). 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 in effect prior to January 1, 1975, and still in effect. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

Respondent Burden: We need this information to determine entitlement to benefits for a veteran's child who is between age 18 and 23 and attending school (38 U.S.C. 104(a)). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

INSTRUCTIONS: Complete either Part I or Part II, and return the completed form to the VA office shown in Item 2.

PART I - VERIFICATION OF SCHOOL ATTENDANCE

(To Be Completed By Claimant)

Benefits have been awarded because the student named in Item 4 expects to start a course of training. Complete Part I, and return this form to the VA office shown in Item 2 within 60 days after the date the student begins the course. If the form is not returned, benefits paid based on school attendance will be discontinued.

NOTE: The form will be signed by the student only if he or she has reached the age of majority and is receiving benefits in his or her own right. The age of majority is determined by State law; it is age 18 in most States. Otherwise, the parent, guardian, or custodian will sign and also enter his or her relationship to the student in Item 8.

7A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID UNDER VA DEPENDENTS' EDUCATIONAL ASSISTANCE (DEA), FEDERAL EMPLOYEES' COMPENSATION ACT OR ANY OTHER FEDERAL AGENCY BENEFIT (U.S. SERVICE ACADEMY, U.S. MERCHANT MARINE ACADEMY, BUREAU OF INDIAN AFFAIRS, ETC.) OF THE UNITED STATES GOVERNMENT?

YES NO (If "Yes," complete Items 7B and 7C)

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.

PART II - VERIFICATION OF TERMINATION OF SCHOOL ATTENDANCE

(To Be Completed By School)

Information has been received that the student named in Item 4 discontinued his or her course of training at your school. Please complete Items 12 through 18 and return this form to the VA office shown in Item 2.

12A. DATE SCHOOL ATTENDANCE TERMINATED (Month, day, year)	12B. IS THIS THE OFFICIAL ENDING DATE OF REGULAR TERM FOR SUCH COURSE?
			YES (If "Yes," complete Item 13A)		NO (If "No," complete Item 13B)
13A. BEGINNING DATE OF THE NEXT REGULAR TERM FOLLOWING	13B. OFFICIAL ENDING DATE OF REGULAR TERM (Month, day, year)
THE DATE STUDENT DISCONTINUED SCHOOL (Month, day, year)
14. REASON FOR TERMINATION OF ATTENDANCE

VA FORM	21-674b	SUPERSEDES VA FORM 21-674b, APR 2015,	Page 1
JUN 2018		WHICH WILL NOT BE USED.

PART II - VERIFICATION OF TERMINATION OF SCHOOL ATTENDANCE (Continued)

(To Be Completed By School)

15. REMARKS

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.

16. NAME OF SCHOOL

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statements or evidence of a material fact, knowing it to be false.

VA FORM 21-674b, JUN 2018

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