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OMB Control No. 2900-0576

Respondent Burden: 3 Minutes

CERTIFICATE OF AFFIRMATION OF ENROLLMENT

AGREEMENT CORRESPONDENCE COURSE

1. FIRST NAME-MIDDLE INITIAL-LAST NAME OF ELIGIBLE PERSON

2. VA FILE NO.

3. NAME OF COURSE

5. NAME AND ADDRESS OF SCHOOL

4. DATE ENROLLMENT

AGREEMENT SIGNED

PURPOSE OF THE AFFIRMATION PROVISION OF LAW

To provide you time (no less than five full days following your signing of an enrollment agreement) during which you can

reflect on your decision to enroll in a correspondence course and determine if such correspondence course is suitable to

your abilities and interests. The Correspondence School Agreement you have signed is not effective unless you complete

this form and return it to the school.

AFFIRMATION PROCEDURE:

A. Decision not to Affirm - If you decide not to affirm the Correspondence School Agreement you have signed, do not

sign this form. Destroy it. Additionally, you may notify the institution, at any time, of your decision not to affirm the

enrollment agreement. The institution, thereupon, without imposing any penalty or fee, shall make full refund of all

amounts paid.

B. Decision to Affirm - If you decide to affirm the Correspondence School Agreement you have signed, you may affirm

only after the expiration of 5 full days after the day on which the agreement was signed. For example, if the contract was

signed on the 1st day of a month, you must sign and date this affirmation certification form on or after the 7th day.

VA WILL NOT ACCEPT ANY AFFIRMATION YOU SIGN BEFORE THE 7TH DAY.

VA WILL NOT PAY FOR LESSONS THAT YOU COMPLETE AND THE SCHOOL SERVICES BEFORE

THE PROPER AFFIRMATION DATE.

TO AFFIRM, READ THE FOLLOWING PARAGRAPH AND COMPLETE ITEMS 6 AND 7 BELOW:

I have read and I understand the enrollment agreement that I entered into with the above named school on the date

indicated in Item 4. By signing this form, I affirm such enrollment agreement and certify, under penalty of law, that I have

not signed this affirmation certificate until after the expiration of 5 full days after the date I signed the aforesaid

enrollment agreement.

(SUBMIT WITH ENROLLMENT CERTIFICATION)

INSTRUCTION TO CLAIMANT: After completion of Items 6 and 7 on or after the 7th day, return VA COPY 1 and

SCHOOL COPY 2 of this form to the school identified in Item 5.

INSTRUCTION TO SCHOOL: Once the student submits VA COPY 1 and SCHOOL COPY 2 of VA Form 22-1999c to

your facility, the school should submit VA COPY 1 of VA Form 22-1999c (Certificate of Affirmation of Enrollment

Agreement For Correspondence Course) and VA Form 22-1999 (Enrollment Certification) to the Department of Veterans

Affairs.

6. DATE SIGNED

7. SIGNATURE OF ELIGIBLE PERSON

VA FORM

22-1999c

SUPERSEDES VA FORM 22-1999c, OCT 2007,

NOV 2008

WHICH WILL NOT BE USED.

Va Form 22-1999c - Certificate Of Affirmation Of Enrollment Agreement Correspondence Course

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