Va Form 22-1990e - Application For Family Member To Use Transferred Benefits Page 3
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4OMB Control No. 2900-0154
Respondent Burden: 15 minutes
APPLICATION FOR FAMILY MEMBER TO USE TRANSFERRED BENEFITS
INTERNET VERSION AVAILABLE - You may complete and send your application over the Internet at:
PART I - APPLICANT INFORMATION
1. SOCIAL SECURITY NUMBER OF APPLICANT
2. SEX OF APPLICANT
3. APPLICANT'S DATE OF BIRTH
Month
Day
Year
MALE
FEMALE
(First, Middle Initial, Last)
4. NAME
5. APPLICANT'S ADDRESS
Number and Street
Apt./Unit Number
City, State, ZIP Code
6A. APPLICANT'S TELEPHONE NUMBERS
(Include Area Code)
Primary:
Secondary:
6B. APPLICANT'S E-MAIL ADDRESS
(If applicable)
(Attach a voided personal check or provide the following information. See instructions for additional Direct Deposit information.)
7. DIRECT DEPOSIT
Account Number
Routing or Transit Number
Account Type
Checking
Savings
8A. RELATIONSHIP TO SERVICE MEMBER
8B. DID YOU RECEIVE A HIGH SCHOOL DIPLOMA OR HIGH SCHOOL EQUIVALENCY CERTIFICATE?
(If "Yes," provide date)
SPOUSE
CHILD
YES
DATE:
NO
PART II - BENEFIT TRANSFERRED AND TYPE AND PROGRAM OF EDUCATION OR TRAINING
(Select one box)
(See instructions for additional information)
9A. BENEFIT TRANSFERRED TO YOU
9B. TYPE OF EDUCATION OR TRAINING
(Including on-line courses)
COLLEGE OR OTHER SCHOOL
CHAPTER 33 - POST-9/11 GI BILL
VOCATIONAL FLIGHT TRAINING
CHAPTER 30 - MONTGOMERY GI BILL EDUCATIONAL
(SAT, CLEP, ETC.)
NATIONAL TEST REIMBURSEMENT
ASSISTANCE PROGRAM (MGIB)
LICENSING OR CERTIFICATION TEST REIMBURSEMENT
CHAPTER 1606 - MONTGOMERY GI BILL-SELECTED
(MCSE, CCNA, EMT, NCLEX, ETC.)
RESERVE EDUCATIONAL ASSISTANCE PROGRAM (MGIB-SR)
APPRENTICESHIP OR ON-THE-JOB
CHAPTER 1607 - RESERVE EDUCATIONAL ASSISTANCE
CORRESPONDENCE
PROGRAM (REAP)
TUITION ASSISTANCE TOP-UP
9B. FULL NAME AND ADDRESS OF SCHOOL, IF KNOWN
VA DATE STAMP
(Do Not Write In This Space)
9C. PLEASE SPECIFY YOUR EDUCATIONAL OR CAREER OBJECTIVE, IF KNOWN
(e.g. Bachelor of Arts in Accounting,
welding certificate, police officer, etc.)
VA FORM
SUPERSEDES VA FORM 22-1990E, JUL 2012,
22-1990E
JUN 2013
WHICH WILL NOT BE USED.
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