Va Form 22-5495 - Dependents' Request For Change Of Program Or Place Of Training
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4OMB Approved No. 2900-0099
Respondent Burden: 15 Minutes
DEPENDENTS' REQUEST FOR CHANGE OF PROGRAM
OR PLACE OF TRAINING
(Under Provisions of Chapters 33 and 35, Title 38, U.S.C.)
INTERNET VERSION AVAILABLE - You may complete and submit your application online at
PART I - APPLICANT INFORMATION
(First, Middle Initial, Last)
VA DATE STAMP
1. NAME
(For VA Use Only)
2. SOCIAL SECURITY NUMBER
3. VA FILE NUMBER
4. SEX OF APPLICANT
5. DATE OF BIRTH
MALE
FEMALE
(Number and street or rural route, city or P.O., State and 9 DIGIT ZIP Code)
6. CURRENT MAILING ADDRESS
(Including Area Code)
7. TELEPHONE NUMBER(S)
PRIMARY
SECONDARY
(if applicable)
8. E-MAIL ADDRESS
(Attach a voided personal check or provide the following information. Direct Deposit not available for DEA benefit payments)
9. DIRECT DEPOSIT
ROUTING OR TRANSIT NUMBER
ACCOUNT NUMBER
ACCOUNT TYPE
CHECKING
SAVINGS
10. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
A. NAME
B. ADDRESS
C. TELEPHONE NUMBER
PART II - QUALIFYING INDIVIDUAL INFORMATION
(First, Middle, Last)
11. NAME OF INDIVIDUAL ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED
13. BRANCH OF SERVICE
12. SOCIAL SECURITY NUMBER OR VA FILE NUMBER
14. DATE OF BIRTH
15. DATE OF DEATH OR DATE LISTED AS MIA OR POW
16. IS QUALIFYING INDIVIDUAL CURRENTLY ON ACTIVE DUTY
YES
NO
17. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL
SPOUSE
SURVIVING SPOUSE
CHILD
STEPCHILD
ADOPTED CHILD
18. DO YOU OR THE QUALIFYING INDIVIDUAL ON WHOSE ACCOUNT YOU ARE CLAIMING BENEFITS HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
YES
NO
PART III - APPLICANT'S MILITARY SERVICE INFORMATION
(NOTE: Chapter 35 benefits are not payable while an eligible person is an active duty)
(If "No," skip to Part IV)
19. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES?
YES
NO
20. INFORMATION ABOUT YOUR PERIODS OF ACTIVE DUTY
A. DATE ENTERED
B. DATE SEPARATED
C. BRANCH OF SERVICE OR RESERVE
D. CHARACTER OF
ACTIVE DUTY
FROM ACTIVE DUTY
OR GUARD COMPONENT
DISCHARGE
VA FORM
SUPERSEDES VA FORM 22-5495, OCT 2010,
22-5495
Page 1
OCT 2011
WHICH WILL NOT BE USED.
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