Va Form 22 5490 – Fill Out and Use This PDF

OMB Approved No. 2900-0098 Respondent Burden: 45 minutes Expiration Date: 10/31/2021

INTERNET VERSION AVAILABLE - You may complete and submit your application online at: www.benefits.va.gov/gibill.

Request to Opt-Out of Information Sharing With Educational Institutions

By checking the box, I CERTIFY THAT THE DEPARTMENT OF VETERANS AFFAIRS (VA) does not have my permission to share information about my veterans' education benefits with any educational institution. I understand that sharing my information with my school is intended to support the certification process and that "opting-out" may delay that process. See Information and Instructions on Page 7 for more information.

PART I - APPLICANT INFORMATION

4.NAME (First name, middle initial, last name)

5.CURRENT MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

6.TELEPHONE NUMBER(S) (Including Area Code)

7.E-MAIL ADDRESS (If applicable)

8.DIRECT DEPOSIT (Attach a voided personal check or provide the following information. See instructions for additional information.)

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

PART II - QUALIFYING INDIVIDUAL INFORMATION

10. NAME OF QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED (First name, middle initial, last name)

16. DO YOU (APPLICANT) OR THE QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) HAVE AN OUTSTANDING FELONY AND/OR WARRANT?

PART III - RELATIONSHIP AND BENEFIT INFORMATION

SECTION I - SPOUSE/SURVIVING SPOUSE

SOCIAL SECURITY NUMBER OF APPLICANT

SECTION I - SPOUSE/SURVIVING SPOUSE (Continued)

20. SPOUSE/SURVIVING SPOUSE SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW:

SECTION II - CHILD/STEPCHILD/ADOPTED CHILD

21. CHILD/STEPCHILD/ADOPTED CHILD SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW:

IMPORTANT: If you are over the age of 18 once you receive either the DEA or FRY SCHOLARSHIP benefits, you will no longer receive payments of Dependency and Indemnity Compensation (DIC) or Pension and you may no longer be claimed as a dependent in a Compensation claim. If you are under the age of 18, on your 18th birthday you will lose eligibility for DIC or Pension payments and you will no longer be claimed as a dependent in a Compensation claim.

CAREFULLY READ THE INFORMATION AND INSTRUCTIONS ON PAGE 6, ITEM 22 BEFORE COMPLETING THE ELECTION BOX BELOW. YOU ARE STRONGLY ENCOURAGED TO DISCUSS YOUR ELECTION WITH A VA COUNSELOR.

22.I CERTIFY THAT I UNDERSTAND THE EFFECTS THAT THIS ELECTION TO RECEIVE DEA OR FRY SCHOLARSHIP BENEFITS WILL HAVE ON MY ELIGIBILITY TO RECEIVE DIC OR PENSION BENEFITS (Please read Information and Instructions Page 6 for additional information)

YES NO

PART IV - BENEFIT AND TYPE OF EDUCATION OR TRAINING INFORMATION

23A. DATE YOU WILL BEGIN SCHOOL OR TRAINING (MM/DD/YYYY)

23B. TYPE OF EDUCATION OR TRAINING (Check ONE box)

COLLEGE OR OTHER SCHOOL

FARM COOPERATIVE

LICENSING OR CERTIFICATION TEST

APPRENTICESHIP OR OTHER ON-THE-JOB TRAINING

NATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDIT

CORRESPONDENCE COURSE

FLIGHT TRAINING (Fry Scholarship only)

SOCIAL SECURITY NUMBER OF APPLICANT

24.NAME AND ADDRESS OF SCHOOL OR TRAINING FACILITY (Number and street or rural route, city or P.O., State and ZIP Code)

25.SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE, IF KNOWN (e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer)

26.WOULD YOU LIKE TO RECEIVE VOCATIONAL AND EDUCATIONAL COUNSELING? (See Information and Instructions, Item 26 for more information regarding vocational and educational counseling)

PART V - APPLICATION HISTORY

27. PRIOR TO THIS APPLICATION, HAVE YOU EVER APPLIED FOR OR RECEIVED ANY OF THE FOLLOWING VA BENEFITS? (Check all appropriate boxes)

IMPORTANT: Complete Items 28 and 29 only if you checked the box for Item 27E above.

28.NAME OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS (First, Middle, Last)

29.SOCIAL SECURITY NUMBER OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS

PART VI - APPLICANT'S MILITARY SERVICE INFORMATION

(NOTE: Chapter 35 benefits are not payable while an eligible person is on active duty)

30. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES? (If "No," skip to Part VII)

31.INFORMATION ABOUT YOUR PERIOD(S) OF ACTIVE DUTY (If you need additional space use Item 37, Remarks)

PART VII - EDUCATION, TRAINING AND EMPLOYMENT

SECTION I - EDUCATION & TRAINING

SOCIAL SECURITY NUMBER OF APPLICANT

PART VII - EDUCATION, TRAINING AND EMPLOYMENT (Continued)

SECTION II - EMPLOYMENT

35. CURRENT AND PAST EMPLOYMENT

NOTE: Complete Items 36A and 36B only if you are a civilian employee of the U.S. Government.

PART VIII - REMARKS, REMINDERS AND VA EDUCATION BENEFITS PAMPHLET

SECTION I - REMARKS

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

SECTION II - REMINDERS

DID YOU REMEMBER TO:

•WRITE YOUR SOCIAL SECURITY NUMBER ON EACH PAGE

•WRITE YOUR COMPLETE MAILING AND EMAIL ADDRESS

•ATTACH SUPPORTING DOCUMENTS (e.g., birth certificate, marriage license, DD214, etc.)

SECTION III - VA EDUCATION BENEFITS PAMPHLET

38.THE MOST CURRENT INFORMATION ON VA EDUCATION BENEFITS IS AVAILABLE ONLINE AT www.benefits.va.gov/gibill. IF YOU WOULD LIKE A COPY OF THE VA EDUCATION BENEFITS PAMPHLET PLEASE CHECK THE BOX.

PART IX - 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.

PENALTY: Willfully 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.

PART X - SIGNATURE OF PARENT, GUARDIAN OR CUSTODIAN

(This section must be completed by the parent, guardian, or custodian if the applicant is a minor)

40.NAME OF PARENT, GUARDIAN, OR CUSTODIAN (First, Middle Initial, Last) (Type or print)

41.MAILING ADDRESS OF PARENT, GUARDIAN, OR CUSTODIAN

Number and Street

Apt./Unit Number

City, State, ZIP Code

42A. TELEPHONE NUMBER(S) OF PARENT, GUARDIAN, OR CUSTODIAN (Include Area Code)

(Please retain these Information and Instructions Pages for future reference)

INFORMATION AND INSTRUCTIONS FOR COMPLETING THE DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS (VA FORM 22-5490)

Do not use this form to apply for Veterans' education assistance based on your own service (chapters 30, 32, 33, or 1606) or Veteran Readiness benefits (chapter 31). To apply for veterans' education assistance based on your own service, use VA Form 22-1990. To apply for Veteran Readiness benefits, use VA Form 28-1900. VA forms are available at www.va. gov/vaforms.

INTERNET VERSION AVAILABLE - You may complete and submit this application on-line at www.benefits.va.gov/gibill. Click on "GI Bill: Apply for Benefits."

NOTE: The numbers on these Information and Instructions pages match the item numbers on this application. Items not mentioned are self-explanatory.

ITEM 8. The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. To enroll in direct deposit, please attach a voided personal check, deposit slip, or provide the information requested in Item 8. 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.

ITEM 16. You will not be eligible to receive benefits for any period for which you or the qualifying individual on whose account you are claiming benefits has an outstanding felony warrant. Any benefits paid to you for such period will result in an overpayment and be subject to collection.

ITEM 17. 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(3)). Additional guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.

ITEM 20. IMPORTANT - PLEASE READ THE INFORMATION BELOW BEFORE MAKING YOUR SELECTION IN ITEM 20A OR 20B REGARDING THE BENEFIT YOU ARE APPLYING FOR.

•To qualify for the Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship, you must be the surviving spouse of an individual who died in the line of duty while serving on active duty as a member of the Armed Forces after September 10, 2001.

•To qualify for Survivor's and Dependents' Educational Assistance (DEA) you must be either:

(1)The spouse of a veteran who is permanently and totally disabled as a result of a service-connected disability, OR

(2)The spouse of an individual on active duty who has been listed as missing in action, captured in the line of duty by

hostile force, forcibly detained or interned in the line of duty by hostile force, or forcibly detained or interned in the line of duty by a foreign government or power for more than 90 days, OR

(3)The surviving spouse or child of a veteran who died of a service-connected disability or who dies while a service-connected disability was rated permanent and total in nature, OR

(4)The surviving spouse of an individual on active duty for which the evidence shows that the individual is hospitalized for receiving outpatient medical care services or treatment; has a total disability permanent in nature incurred or aggravated in the line of duty

in the active military, naval, or air service; and the service person is likely to be discharged or released from such service for such disability.

NOTE: If you are eligible for both Chapter 35 Survivors' and Dependents' Educational Assistance Program (DEA) and Chapter 33 Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship (Fry Scholarship) benefits, you must relinquish/give up entitlement to one or the other benefit for which you are eligible, even if entitlement arises from separate events. In other words, you must forfeit eligibility to the other benefit even if your eligibility is due to:

•A separate Period of Service (POS) other than the one for which the death of the spouse is associated; OR

•A separate POS other than the one for which your spouse has a total disability permanent in nature resulting from a service-connected disability; OR

•A separate POS based on any other criteria as listed in 38 U.S.C. § 3501(a)(1); OR

•Death of any other individual identified in Item 10 of this application.

IMPORTANT: You cannot retain eligibility for both programs simultaneously. Therefore, by checking either box "A" or box "B" in Item 20, you agree and understand that you are making an irrevocable election to receive the selected benefit and your election may not be changed.

IMPORTANT: Eligibility for (DEA) will be terminated in the event that VA determines that the individual on whose account benefits are claimed is no longer totally disabled or VA is notified that the individual is no longer listed as captured, missing in action, or forcibly detained.

Note: Before making your election selection, you can compare the differences between (DEA) and (FRY), and the benefits each provide in order to help you make the best choice that suits your needs. This benefit comparison information can be found on the VA website at: https://www.benefits.va.gov/gibill/docs/factsheets/fry_scholarship.pdf. You can also find additional information about each program by visiting the GI Bill website at: https://benefits.va.gov/gibill/ and using the comparison tool.

HOW TO FILE YOUR CLAIM

You may complete and submit your application online at www.benefits.va.gov/gibill or 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 region of that school's physical address. See page 8 for addresses of the 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 submit 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 have not selected a school or training establishment:

Step 1: Mail the completed application to the VA Regional Processing Office for the region of your home address. Check page 8 for addresses of the 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.

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 known 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 individual is entitled. However, you may elect to "opt-out" of these disclosures and have VA withhold this information instead.

ADDITIONAL HELP COMPLETING APPLICATION

If you need additional help completing this application or you want information about the work-study program, call VA toll-free at 1-888-GIBILL-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 more information about education assistance from our education Internet site at www.benefits.va.gov/gibill.

CONTACT VA FROM OVERSEAS

Students and School Certifying Officials calling from outside the United States can contact VA by phone at:

001-918-781-5678 during business hours, 7 a.m. - 6 p.m. CST, Monday - Friday. This is not a toll-free number but the caller will be routed to the next available customer service representative. Non-overseas customers should call the toll- free number shown in "Additional Help Completing Application".

Eastern Region:

VA Regional Office

P.O. Box 4616

Buffalo, NY 14240-4616

SERVES THE FOLLOWING STATES

Western Region:

VA Regional Office

P.O. Box 8888

Muskogee, OK 74402-8888

SERVES THE FOLLOWING STATES

PRIVACY ACT INFORMATION: 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., awards of benefits) 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 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. 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 requested information is considered relevant and necessary to determine the maximum benefits allowable under the law. While you do not have to respond, VA cannot process your claim for benefits unless the information is furnished as required by existing law (38 U.S.C. 3513). 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 your eligibility for education benefits (38 U.S.C. 3513). Title 38 U.S.C. allows us to ask for this information. We estimate that you will need an average of 45 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 http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-888-GI- BILL-1 (1-888-442-4551) to get information on where to send comments or suggestions about this form.