Va Form Information – Fill Out and Use This PDF

OMB Approved No. 2900-0358

Respondent Burden: 30 Minutes

SUPPLEMENTAL INFORMATION FOR CHANGE OF PROGRAM OR REENROLLMENT

AFTER UNSATISFACTORY ATTENDANCE, CONDUCT OR PROGRESS

INSTRUCTIONS: Please furnish the information requested in Part I (Item 3) or Part II (Item 4) checked below. Disregard any item not checked. Also attach any related information that you would like to have considered when VA evaluates your claim. If you need more space for continuing your answer to an item, use the back of this form. Place your additional information in item 5, Remarks. Alternately, attach a separate sheet of paper with your additional information to this form.

PART I - CHANGE OF PROGRAM

3. YOU HAVE CHANGED YOUR EDUCATIONAL OBJECTIVE (PROGRAM). STATE WHY THIS NEW PROGRAM IS THE RIGHT PROGRAM FOR YOU.

PART II - UNSATISFACTORY ATTENDANCE, CONDUCT OR PROGRESS

4.YOUR PREVIOUS SCHOOL STATED THAT YOUR ATTENDANCE, CONDUCT OR PROGRESS WAS UNSATISFACTORY. IF YOU NEED MORE SPACE FOR YOUR INFORMATION, USE THE BACK OF THIS FORM OR ATTACH A SEPARATE PIECE OF PAPER.

A.STATE WHY YOU HAD UNSATISFACTORY ATTENDANCE, CONDUCT OR PROGRESS.

B. STATE WHAT STEPS OR PRECAUTIONS YOU HAVE TAKEN TO ENSURE THAT THE UNSATISFACTORY ATTENDANCE, CONDUCT, OR PROGRESS WILL NOT HAPPEN AGAIN.

C. STATE WHY THIS NEW PROGRAM IS THE RIGHT PROGRAM FOR YOU.

PART III - OTHER INFORMATION

5 . REMARKS

I HEREBY CERTIFY THAT the statements contained herein are true and complete to the best of my knowledge and belief.

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 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. An example of a routine use allows the VA to send educational forms or letters with a individual's identifying information to the individual's school or training establishment to (1) assist the individual in the completion of claims forms or (2) for the VA to obtain further information as may be necessary from the school for the VA to properly process the individual's education claim or to monitor his or her progress during training. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The 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 enacted before January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine the maximum benefits under the law. While you do not have to respond, VA cannot process your claim for education assistance unless the information is furnished as required by existing law (38 U.S.C. 3471). The responses you submit are considered confidential (38 U.S.C. 5701). Any information provided by applicants, recipients, and others may be subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine your eligibility for additional educational benefits for a change of program or reenrollment after unsatisfactory attendance, conduct or progress. (38 U.S.C. sections 3474, 3524 and 3691). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. 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 information collection.

VA FORM 22-8873, AUG 2009