Form 28-8739a at a glance
What it is: The Protection of Privacy Information Statement is for use by counselees and rehabilitation program participants.
Who signs: Sign: Veteran's Signature, Date Signed.
A filled-in Form 28-8739a example: a veteran signs the statement
How to fill out Form 28-8739a, box by box
Veteran's Signature
By signing, you certify that the information you have given is true and correct to the best of your knowledge and belief.
More rules for Form 28-8739a
The information requested is needed to assist in vocational and educational planning, to authorize receipt of rehabilitation services, to develop a record of vocational progress, and to assure the best results from the rehabilitation program.
Giving the requested information is voluntary.
If you do not give this information: (1) you may not receive the maximum benefit either from counseling or from your education or rehabilitation program. (2) If certain information is required before you may enter a VA program, failing to give it may result in not receiving the education or rehabilitation benefit for which you have applied. (3) If you are in a program in which information on your progress is required, failing to give it may result in not receiving further benefits or services. Failing to give it will not have a negative effect on any other benefit to which you may be entitled.
Your responses may be disclosed outside VA only if the disclosure is authorized under the Privacy Act of 1974.
Sources
[1] VA Form 28-8739a (AUG 2005), Protection of Privacy Information Statement, Department of Veterans Affairs (the Official source link on this page).