Va Form 22-1990t - Application For Individualized Tutorial Assistance

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OMB Approved No. 2900-0171

Respondent Burden: 30 minutes

Expiration Date: 03/31/2018

APPLICATION FOR INDIVIDUALIZED TUTORIAL ASSISTANCE

1. NAME OF

APPLICANT

FIRST NAME

M.I.

LAST NAME

2. NAME OF

VETERAN

(If other than

applicant)

FIRST NAME

M.I.

LAST NAME

3. MAILING ADDRESS

4A. VA FILE NUMBER

4B. PAYEE

NUMBER AND STREET OR RURAL ROUTE

SOCIAL SECURITY NUMBER

APARTMENT OR BOX NUMBER

5. SEX

6. DATE OF BIRTH

CITY OR POST OFFICE

FEMALE

MALE

MONTH

DAY

YEAR

STATE

ZIP CODE OR FOREIGN MAIL CODE

7. NAME OF YOUR COURSE OR CURRICULUM

8. CREDIT OR CLOCK HOUR LOAD

9. FINAL EDUCATIONAL, PROFESSIONAL, OR

VOCATIONAL GOAL

10. UNIT SUBJECT OR SUBJECTS IN WHICH YOU REQUIRE INDIVIDUALIZED

11. NAME, POSITION AND ADDRESS OF TUTOR

TUTORING

12. SCHEDULE AND CHARGES FOR TUTORIAL ASSISTANCE

A. MONTH AND

B. EXACT DATES

C. NUMBER OF HOURS

D. CHARGE PER

E. TOTAL CHARGES

YEAR

OF SESSIONS

OF INSTRUCTION THIS MONTH

HOUR

THIS MONTH

F. TOTAL PAYMENT DUE

13A. SIGNATURE OF APPLICANT (Do NOT print)

13B. DATE SIGNED

13C. E-MAIL ADDRESS OF APPLICANT

I CERTIFY THAT: (1) I gave the applicant individualized tutorial assistance as shown above; (2) the charges to the applicant shown

above are correct; and (3) I am not a close relative (i.e., spouse, parent, child, brother, sister) of the applicant.

14A. SIGNATURE OF TUTOR (Do NOT print)

14B. DATE SIGNED

I CERTIFY THAT: (1) The individualized tutorial assistance for the unit subject or subjects shown was required for the satisfactory

pursuit of the student's approved program; (2) the tutor is qualified to conduct individualized tutorial assistance; and (3) the charges do

not exceed the customary charges for other students who receive the same tutorial assistance.

15. NAME AND ADDRESS OF EDUCATIONAL INSTITUTION

16. INDICATE TYPE OF SCHOOL

FOUR-YEAR

TWO-YEAR

OTHER THAN

COLLEGE

17A. SIGNATURE AND TITLE OF CERTIFYING OFFICIAL

17B. DATE SIGNED

Additional Certification required to receive tutorial assistance under the Post-9/11 GI Bill (chapter 33)

I CERTIFY THAT: (1) Tutorial assistance benefits are essential to correct a deficiency of this student in the course and; (2) that the

course is required as part of, or is prerequisite or indispensable to the satisfactory pursuit of, an approved program of education.

18A. SIGNATURE OF PROFESSOR OR INSTRUCTOR

18B. DATE SIGNED

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,

knowing it to be false.

FOR VA USE ONLY

SIGNATURE OF FINANCE OFFICER (or designee)

APPROVAL DATE

SIGNATURE OF ADJUDICATOR

DATE

STATION

NUMBER

VA FORM

SUPERSEDES VA FORM 22-1990t, JAN 2014,

22-1990t

DEC 2016