Fillable Va Form 22-0810 - Application For Reimbursement Of National Exam Fee printable pdf download

Va Form 22-0810 - Application For Reimbursement Of National Exam Fee

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OMB Control No. 2900-0706

Respondent Burden: 15 minutes

APPLICATION FOR REIMBURSEMENT OF NATIONAL EXAM FEE

(See General Information on Reverse)

Please read the Privacy Act and Respondent Burden information on the reverse before completing the form.

IMPORTANT: Complete this application to apply for reimbursement of a national exam fee (one exam per form). You must apply separately for VA

benefits if you have not already done so.

(SEE REVERSE FOR INFORMATION AND INSTRUCTIONS BEFORE COMPLETING THIS FORM)

Part I - IDENTIFICATION INFORMATION

(First, Middle Initial, Last Name)

1. APPLICANT'S NAME

(Number and street or rural route, P.O. Box, City, State, ZIP Code)

2. APPLICANT'S ADDRESS

(Include Area Code) (Indicate hours you can be reached)

3. TELEPHONE NUMBER

4. SOCIAL SECURITY NUMBER OF APPLICANT

DAYTIME

EVENING

(For chapter 35, enter the veteran's file number and include your suffix indicator. For chapter 30 dependent's case, enter the file number of the

5. VA FILE NUMBER

person who transferred entitlement to you.)

6. VA EDUCATION INFORMATION

A. HAVE YOU PREVIOUSLY APPLIED FOR VA EDUCATION BENEFITS?

YES

(If "Yes," show the specific benefit you previously applied for in Item 6B)

(If "No," you must also complete an Application for VA Education Benefits, VA Form 22-1990)

B. WHAT EDUCATION BENEFIT HAVE YOU APPLIED FOR PREVIOUSLY?

C. UNDER WHAT EDUCATION BENEFIT ARE YOU NOW APPLYING FOR EXAM FEE REIMBURSEMENT?

Post-9/11 GI Bill (Chapter 33)

Montgomery GI Bill - Active Duty Educational Assistance Program (MGIB) (Chapter 30)

Post-Vietnam Era Veterans Educational Program (VEAP) (Chapter 32)

Survivors' and Dependents' Educational Assistance Program (DEA) (Chapter 35)

Montgomery GI Bill - Selected Reserve Educational Assistance Program (MGIB-SR) (Chapter 1606)

Reserve Educational Assistance Program (REAP) (Chapter 1607)

National Call to Service (NCS)

Part II - EXAM INFORMATION (Specify each item for this exam)

(Attach receipt)

7. NAME OF EXAM

10. ITEMIZE EXAM COST INCLUDING FEES

(Indicate if taken online)

8. ORGANIZATION GIVING EXAM

9. DATE EXAM TAKEN

(Optional)

11. REMARKS

Part III - CERTIFICATION AND SIGNATURE OF APPLICANT

I CERTIFY THAT the information above is 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 payable by VA may result in a fine, imprisonment, or both.

(Do NOT print)

12. SIGNATURE OF APPLICANT

13. DATE SIGNED

IMPORTANT - Please return this form and a copy of the receipt for exam fees to the VA Office that handles your area. See the VA Regional Office

addresses on the reverse of this form. VA will request a copy of your exam results only if needed.

SUPERSEDES VA FORM 22-0810, MAY 2011,

VA FORM

22-0810

WHICH WILL NOT BE USED.

JUL 2012